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Abstract: Background: Esophageal dysmotility may predispose to Barrett's esophagus (BE). We hypothesized that high‐resolution manometry (HRM) performed with additional physiologic challenge would better delineate dysmotility in BE. Methods: Included patients had typical reflux symptoms and underwent endoscopy, HRM with single water swallows and adjunctive testing with solids and rapid drink challenge (RDC) before ambulatory pH‐impedance monitoring. BE and endoscopy‐negative reflux disease (ENRD) subjects were compared against functional heartburn patient‐controls (FHC). Primary outcome was incidence of HRM contractile abnormalities with standard and adjunctive swallows. Secondary outcomes included clearance measures and symptom association on pH‐impedance. Key Results: Seventy‐eight patients (BE 25, ENRD 27, FHC 26) were included. Water swallow contractility was reduced in both BE (median DCI 87 mm Hg/cm/s) and ENRD (442 mm Hg/cm/s) compared to FHC (602 mm Hg/cm/s; P < .001 and .04, respectively). With the challenge of solid swallows and RDC, these parameters improved in ENRD (solids = 1732 mm Hg/cm/s), becoming similar to FHC (1242 mm Hg/cm/s; P = .93), whereas abnormalities persisted in BE (818 mm Hg/cm/s; P < .01 c.f. FHC). In BE and ENRD, reflux events (67 vs 57 events/24 hour) and symptom frequency were similar; yet symptom correlation was significantly better in ENRD compared to BE, which was comparable to FHC (symptom index 30% vs 4% vs 0%, respectively). Furthermore, bolus clearance and exposure times were more pronounced in BE (P < .01). Conclusions & Inferences: Reduced contractile effectiveness persisted in BE with the more representative esophageal challenge of swallowing solids and free drinking; while in ENRD and FHC peristalsis usually improved, demonstrating peristaltic reserve. Furthermore, symptom association and refluxate clearance were reduced in BE. These factors may underlie BE pathogenesis. [ABSTRACT FROM AUTHOR]

Abstract: Background: Advances in clinical measurement of esophageal motility and function have improved the assessment of swallowing disorders and reflux symptoms. Variation in data acquisition, analysis, and reporting exists and impacts on diagnosis and management. Aims and Methods: This study examined variation in esophageal manometry methodology between institutions to establish the status in current practice. A structured survey was distributed through international NGM societies using an Internet‐based platform. Questions explored infrastructure, technology, analysis, and reporting. Key Results: Responses were received from 91 centers from 29 countries. Eighteen (20%) centers used “conventional” manometry, 75 (82%) high‐resolution manometry, and 53 (58%) HR impedance manometry. All centers documented motility for single water swallows. The Chicago Classification was applied by 65 (71.4%) centers. In contrast, analysis of EGJ morphology varied widely. Adjunctive testing was often applied: multiple rapid swallows (77%), rapid drink challenge (77%), single solid swallows (63%), and a standard test meal (18%). Of 86 (94.5%) units that offered pH impedance (pH‐Z) studies, approximately half (53.5%) performed tests on acid‐suppressant medication in patients with a high pretest probability (eg, erosive esophagitis). Most (75.6%) centers manually reviewed every reflux event. Others examined pH‐Z data only prior to symptoms. To assess symptom association with reflux events, 73.6% centers analyzed each symptom separately, whereas 29.7% centers pooled symptoms. Conclusions and Inferences: There is marked variation in the data acquisition, analysis, and reporting of esophageal manometry studies. Further efforts to improve quality and uniformity in testing and reporting are required. This survey provides information upon which best‐practice guidelines can be developed. [ABSTRACT FROM AUTHOR]

Background/Aims The Chicago Classification for diagnosis of esophageal motility disorders by high-resolution manometry ( HRM) is based on single water swallows ( SWS). Emerging data suggest that a 'Rapid Drink Challenge' ( RDC) increases sensitivity for motility disorders. This study establishes normal values and diagnostic thresholds for RDC in clinical practice. Methods Two cohort studies were performed in patients with dysphagia or reflux symptoms (development and validation sets). Healthy subjects and patient controls provided reference values. Ten SWS and two 200-mL RDC were performed. Primary diagnosis for SWS was established by the Chicago Classification. Abnormal RDC was defined by impaired esophagogastric junction ( EGJ) function (elevated integrated relaxation pressure during RDC [ IRP- RDC]); incomplete inhibition of contractility during and ineffective contraction after RDC. Diagnostic thresholds identified in the development set were prospectively tested in the validation set. Results Normal values were determined in healthy (n=95; age 37.8 ± 12) and patient controls (n=44; age 46.4 ± 15). Development and validation sets included 178 (54 ± 17 years) and 226 (53 ± 16 years) patients, respectively. Integrated relaxation pressure during RDC was higher for SWS than RDC in all groups (overall P<.001), except achalasia. Rapid Drink Challenge suppressed contractility, except in achalasia type III, spasm, and hypercontractile motility disorders ( P<.001). An effective after-contraction was present more often in health than disease ( P<.001). Optimal diagnostic thresholds identified in the development set ( IRP- RDC ≥12 mmHg achalasia, IRP- RDC ≥ 8mmHg 'all cause' EGJ dysfunction), were confirmed in the validation set (both, sensitivity ~85%, specificity >95%). Conclusions Rapid Drink Challenge contributes clinically relevant information to routine HRM studies, especially in patients with EGJ dysfunction. [ABSTRACT FROM AUTHOR]

SUMMARY. High-resolution esophageal manometry (HRM) is a recent development used in the evaluation of esophageal function. Our aim was to assess the inter-observer agreement for diagnosis of esophageal motility disorders using this technology. Practitioners registered on the HRM Working Group website were invited to review and classify (i) 147 individual water swallows and (ii) 40 diagnostic studies comprising 10 swallows using a drop-down menu that followed the Chicago Classification system. Data were presented using a standardized format with pressure contours without a summary of HRM metrics. The sequence of swallows was fixed for each user but randomized between users to avoid sequence bias. Participants were blinded to other entries. (i) Individual swallows were assessed by 18 practitioners (13 institutions). Consensus agreement (⩽2/18 dissenters) was present for most cases of normal peristalsis and achalasia but not for cases of peristaltic dysmotility. (ii) Diagnostic studies were assessed by 36 practitioners (28 institutions). Overall inter-observer agreement was 'moderate' (kappa 0.51) being 'substantial' (kappa > 0.7) for achalasia type I/II and no lower than 'fair-moderate' (kappa >0.34) for any diagnosis. Overall agreement was somewhat higher among those that had performed >400 studies (n = 9; kappa 0.55) and 'substantial' among experts involved in development of the Chicago Classification system (n = 4; kappa 0.66). This prospective, randomized, and blinded study reports an acceptable level of inter-observer agreement for HRM diagnoses across the full spectrum of esophageal motility disorders for a large group of clinicians working in a range of medical institutions. Suboptimal agreement for diagnosis of peristaltic motility disorders highlights contribution of objective HRM metrics. [ABSTRACT FROM AUTHOR]

Background In the absence of major dysmotility, esophageal manometry with water swallows rarely explains the causes of esophageal symptoms and disease. This methodology development study assessed esophageal function and symptoms during a test meal in patients with reflux symptoms and asymptomatic controls. The impact of this approach on manometric diagnosis and clinical outcome was reviewed. Methods 18 patients with reflux symptoms and 10 healthy volunteers underwent high resolution manometry (HRM) with 5 mL water swallows, 200 mL water drink, and standardized solid test meal followed by 10 min postprandial observation. The number of symptoms associated with esophageal dysfunction ( SAD) divided by total symptoms (dysfunction symptom index [D-SI]) was calculated. Ambulatory reflux pH-monitoring was performed. Final diagnosis and clinical outcome were documented at 2 years. Key Results Meal intake took longer in patients than controls (552 vs 339 s) and this was associated with a higher number of ineffective swallows in this group (51% vs 28%; p < 0.001). No swallowing problems occurred with water swallows but 12/18 (66%) patients had SAD during either the meal or postprandial observations with D- SI >50% in 9/12 (75%). Compared with water swallows, manometric classification was altered in 12/18 (67%) and clinical diagnosis was altered in 7/18 (39%) patients due to test meal observations. Conclusions & Inferences A novel methodology for the detection of symptomatic dysmotility during a test meal and postprandial observation is presented. This technique increased the diagnostic yield of esophageal dysfunction in patients presenting with reflux symptoms. Long-term follow-up indicated that these observations can guide effective clinical management. [ABSTRACT FROM AUTHOR]

Background Measurement of esophago-gastric junction ( EGJ) cross-sectional area ( CSA) and distensibility by an Endolumenal Functional Lumen Imaging Probe (Endo FLIP®) may distinguish between gastro-esophageal reflux disease ( GERD) patients and healthy volunteers ( HV). We aimed to assess the agreement of Endo FLIP® measurements with clinical and physiologic diagnosis of GERD. Methods Twenty-one HV and 18 patients with typical GERD symptoms were studied. After gastroscopy, EGJ CSA, and distensibility were measured by Endo FLIP®. Forty-eight hour esophageal pH monitoring was then performed by a wireless system. The ability of Endo FLIP® to discriminate GERD patient and HVs was assessed. Planned secondary analysis then assessed whether EGJ CSA and distensibility were increased in individuals with pathologic acid exposure. Key Results Healthy volunteers were younger and had lower body mass index ( BMI; both p < 0.001). Pathologic acid exposure was present in 3/21 (14%) HVs and 9/18 (50%) patients ( p = 0.126). At 30 mL Endo FLIP® bag volume, EGJ CSA was higher ( p = 0.058) and EGJ distensibility was lower ( p = 0.020) in HVs than patients. Secondary analysis showed that EGJ measurements were similar in participants with and without pathologic acid exposure ( CSA 98 mm2 vs 107 mm2; p = 0.789, distensibility; p = 0.704). An inverse association between BMI and CSA ( R2 = 0.2758, p = 0.001) and distensibility ( R2 = 0.2005, p = 0.005) was present. Conclusions & Inferences Endolumenal Functional Lumen Imaging Probe is not useful for GERD diagnosis because EGJ CSA and distensibility do not distinguish between HVs and GERD patients defined by clinical presentation or pH measurement. This unexpected result may be due to an important, confounding interaction of obesity. [ABSTRACT FROM AUTHOR]

Background Alginates form a raft above the gastric contents, which may suppress gastro-oesophageal reflux; however, inconsistent effects have been reported in mechanistic and clinical studies. Aims To visualise reflux suppression by an alginate-antacid [Gaviscon Advance (GA), Reckitt Benckiser, UK] compared with a nonraft-forming antacid using magnetic resonance imaging (MRI), and to determine the feasibility of pH-impedance monitoring for assessment of reflux suppression by alginates. Methods Two studies were performed: (i) GA and antacid (Alucol, Wander Ltd, Switzerland) were visualised in the stomach after ingestion in 12 healthy volunteers over 30 min after a meal by MRI, with reflux events documented by manometry. (ii) A randomised controlled, double-blind cross-over trial of post-prandial reflux suppression documented by pH-impedance in 20 patients randomised to GA or antacid (Milk of Magnesia; Boots, UK) after two meals taken 24 h apart. Results MRI visualized a 'mass' of GA form at the oesophago-gastric junction ( OGJ); simple antacid sank to the distal stomach. The number of post-prandial common cavity reflux events was less with GA than antacid [median 2 (0-5) vs. 5 (1-11); P < 0.035]. Distal reflux events and acid exposure measured by pH-impedance were similar after GA and antacid. There was a trend to reduced proximal reflux events with GA compared with antacid [10.5 (8.9) vs. 13.9 (8.3); P = 0.070]. Conclusions Gaviscon Advance forms a 'mass' close to the OGJ and significantly suppresses reflux compared with a nonraft-forming antacid. Standard pH-impedance monitoring is suitable for clinical studies of GA in gastro-oesophageal reflux disease patients where proximal reflux is the primary outcome. [ABSTRACT FROM AUTHOR]

The pathophysiology of chronic cough and its association with dsymotility and laryngopharyngeal reflux remains unclear. This study applied high-resolution manometry (HRM) to obtain a detailed evaluation of pharyngeal and esophageal motility in chronic cough patients with and without a positive reflux-cough symptom association probability (SAP). Retrospective analysis of 66 consecutive patients referred for investigation of chronic cough was performed. Thirty-four (52%) were eligible for inclusion (age 55 [19-77], 62% female). HRM (ManoScan 360, Given/Sierra Scientific Instruments, Mountain View, CA) with 10 water swallows was performed followed by a 24-hour ambulatory pH monitoring. Of this group, 21 (62%) patients had negative reflux-cough SAP (group A) and 13 (38%) had positive SAP (group B). Results from 23 healthy controls were available for comparison (group C). Detailed analysis revealed considerable heterogeneity. A small number of patients had pathological upper esophageal sphincter (UES) function ( n = 9) or esophageal dysmotility ( n = 1). The overall baseline UES pressure was similar, but average UES residual pressure was higher in groups A and B than in control group C (−0.2 and −0.8 mmHg vs. −5.4 mmHg; P < 0.018 and P < 0.005). The percentage of primary peristaltic contractions was lower in group B than in groups A and C (56% vs. 79% and 87%; P = 0.03 and P < 0.002). Additionally, intrabolus pressure at the lower esophageal sphincter was higher in group B than in group C (15.5 vs. 8.9; P = 0.024). HRM revealed changes to UES and esophageal motility in patients with chronic cough that are associated with impaired bolus clearance. These changes were most marked in group B patients with a positive reflux-cough symptom association. [ABSTRACT FROM AUTHOR]

Background Obese patients have an increased risk of gastro-oesophageal reflux disease; however, the mechanism underlying this association is uncertain. Aim To test the hypothesis that mechanical effects of obesity on oesophageal function increase acid exposure and symptoms. Methods Height, weight and waist circumference ( WC) were measured in patients with typical reflux symptoms referred for manometry and 24 h ambulatory pH studies. Symptom severity was assessed by questionnaire. The association between obesity [ WC, body mass index (BMI)], oesophageal function, acid exposure and reflux symptoms was assessed. Results Physiological measurements were obtained from 582 patients (median age 48, 56% female) of whom 406 (70%) completed symptom questionnaires. The prevalence of general obesity was greater in women ( BMI ≥ 30 kg/m2; F 23%:M 16%; P = 0.056), however more men had abdominal obesity ( WC ≥ 99 cm (M 41%:F 28%; P = 0.001)). Oesophageal acid exposure increased with obesity ( WC: R = 0.284, P < 0.001) and was associated also with lower oesophageal sphincter ( LOS) pressure, reduced abdominal LOS length and peristaltic dysfunction (all P < 0.001). Univariable regression showed a negative association of WC with both LOS pressure and abdominal LOS length ( R = −0.221 and −0.209 respectively; both P < 0.001). However, multivariable analysis demonstrated that the effects of increasing WC on oesophageal function do not explain increased acid reflux in obese patients. Instead, independent effects of obesity and oesophageal dysfunction on acid exposure were present. Reflux symptoms increased with acid exposure ( R = 0.300; P < 0.001) and this association explained increased symptom severity in obese patients. Conclusions Abdominal obesity ( waist circumference) is associated with oesophageal dysfunction, increased acid exposure and reflux symptoms; however, this analysis does not support the mechanical hypothesis that the effects of obesity on oesophageal function are the cause of increased acid exposure in obese patients. [ABSTRACT FROM AUTHOR]

Background Symptom based diagnosis is not reliable in patients with swallowing problems, heartburn, and other dyspeptic complaints. The aim of investigation is to provide clinically relevant measurements of gastrointestinal structure and function that explain the cause of symptoms, identify pathology, and guide effective management. Current practice rarely meets these ideals. Purpose This review considers recent advances in technology such as high-resolution manometry (HRM) with esophageal pressure topography (EPT), HRM with impedance, high frequency ultrasound, and endoscopic functional luminal impedance planimetry (Endo-FLIP) that provide new opportunities to identify the pathophysiologic basis of esophageal symptoms and disease. As experience with these new devices increases researchers are developing new methodologies that maximize their utility in clinical practice. For example, application of HRM to assess motility and function during and after a test meal can identify the causes of swallowing problems, reflux and other postprandial symptoms and intra-operative application of Endo-FLIP may help surgeons perform antireflux surgery. These examples illustrate the potential of physiologic measurement to direct rational and effective clinical management for individual patients. [ABSTRACT FROM AUTHOR]

Non-specific esophageal dysmotility with impaired clearance is often present in patients with gastro-esophageal reflux disease (GERD), especially those with erosive disease; however the physio-mechanic basis of esophageal dysfunction is not well defined. Retrospective assessment of patients with erosive reflux disease (ERD; n = 20) and endoscopy negative reflux disease (ENRD; n = 20) with pathologic acid exposure on pH studies (>4.2% time/24 h) and also healthy controls (n = 20) studied by high resolution manometry. Esophageal motility in response to liquid and solid bolus swallows and multiple water swallows (MWS) was analyzed. Peristaltic dysfunction was defined as failed peristalsis, spasm, weak or poorly coordinated esophageal contraction (>3 cm break in 30 mmHg isocontour). Peristaltic dysfunction was present in 33% of water swallows in controls, 56% ENRD and 76% ERD respectively (P < 0.023 vs controls, P = 0.185 vs ENRD). The proportion of effective peristaltic contractions improved with solid compared to liquid bolus in controls (18% vs 33%, P = 0.082) and ENRD (22% vs 54%, P = 0.046) but not ERD (62% vs 76%, P = 0.438). Similarly, MWS was followed by effective peristalsis in 83% of controls and 70% ENRD but only 30% ERD patients (P < 0.017 vs controls and P < 0.031 vs ENRD). The association between acid exposure and dysmotility was closer for solid than liquid swallows (r = 0.52 vs 0.27). Peristaltic dysfunction is common in GERD. ERD patients are characterized by a failure to respond to the physiologic challenge of solid bolus and MWS that is likely also to impair clearance following reflux events and increase exposure to gastric refluxate. [ABSTRACT FROM AUTHOR]

High-resolution manometry (HRM) with spatiotemporal representation of pressure data is a recent advance in esophageal measurement. At present, normal values are available for 5 mL water swallows in the supine position. This study provides reference values for liquid and solid bolus swallows in the upright seated and supine positions. A total of 23 asymptomatic volunteers (11M : 12F, age 20-56) underwent HRM (Manoscan 360; Sierra Scientific Instruments) with 5 mL water and 1 cm bread swallows in the upright and supine positions. Normal values for primary parameters associated with effective bolus transport [proximal transition zone length (PTZ, assesses peristaltic coordination], contraction front velocity (CFV), distal contractile index (DCI) and integrated relaxation pressure (IRP)] are presented. For each parameter, median values along with the 5-95th percentile range are reported. Inter-observer agreement between independent observers is reported using the intra-class correlation coefficient. A higher proportion of swallows were peristaltic for liquids than solids in both the upright and supine positions (both P < 0.05). As workload increases with solid bolus and on moving from the upright to the supine position the esophageal contractile response resulted in a shorter PTZ, a slower CFV, and a more vigorous DCI. Also IRP increased during solid bolus transit (all P < 0.01). There was significant agreement between independent observers for HRM parameters. Normative values for esophageal function for solids as well as liquids and in the 'physiologic', upright position will optimize the utility of HRM studies. The high level of inter-observer agreement indicates that these can be applied as reference values in clinical practice. [ABSTRACT FROM AUTHOR]

Catheter-based esophageal pH-monitoring is used to evaluate patients with suspected gastro-esophageal reflux disease (GERD); however false-negative results may occur due to poor tolerance of the catheter with reduced oral intake and activity, or high day-to-day variation in reflux and symptom events. We assessed diagnostic yield and clinical impact of prolonged, wireless pH-monitoring in patients with negative results from 24-h catheter-based studies and ongoing symptoms. Esophageal acid exposure (percentage time pH <4), Symptom Index, and Symptom Association Probability (SAP) were calculated. Diagnostic yield was assessed using Average (mean) and Worst Day (24-h period with highest acid exposure or symptom load) analyses. Outcome data were assessed 6-36 months (median 24) after initiation of definitive therapy based on physiologic testing. Data from prolonged pH-monitoring up to 96-h (median 72-h) were available from 38 patients. Using Average and Worst Day analysis, esophageal acid exposure was pathologic in 37% and 47%, whereas SAP was positive in 34% and 63% of patients, respectively. Overall using Average and Worst Day analyses, 61% and 76% patients were diagnosed with GERD based on either pathologic acid exposure or positive symptom association. Of 12 patients that underwent antireflux surgery, 10(83%) reported a good outcome at a median 24 months follow-up. Prolonged, wireless pH-monitoring increases test sensitivity and diagnostic yield in patients with continuing esophageal symptoms despite negative 24-h catheter-based pH-studies. Without a definitive diagnosis, many would not have received effective treatment. [ABSTRACT FROM AUTHOR]

Background Standard pH monitoring is performed over 24 h with a naso-oesophageal catheter (C-pH). Limitations include naso-pharyngeal discomfort, nausea and social embarrassment resulting in reduced reflux-provoking activities. Recently a catheter-free pH-monitoring technique has become available. The tolerability and diagnostic yield of this system in patients who failed standard monitoring remain unknown. Aim To examine the tolerability and diagnostic outcome of catheter-free pH-monitoring technique in patients who failed standard monitoring. Methods Patients referred for C-pH and catheter-free pH monitoring completed a tolerability questionnaire. Acid exposure in the distal oesophagus and symptom index (SI) were reviewed. Results Over 4 years, 883/1751 (50%) of patients with typical reflux symptoms referred for C-pH were diagnosed with gastro-oesophageal reflux disease (GERD) based on a pathological percentage time acid exposure (%time pH <4);134 (8%) patients failed C-pH and, of these, 129 successfully completed 2-day catheter-free pH monitoring. Ninety-eight (76%) of these patients had a pathological percentage pH <4 on either day compared with 49/102 (49%) of contemporaneous C-pH patients ( P < 0.01). There was no difference in SI for heartburn (35% vs. 42%; P = 0.49). The questionnaire demonstrated a preference for catheter-free pH monitoring (96%) with less restriction in activities of daily living, naso-pharyngeal discomfort, dysphagia and chest pain. Conclusions Tolerance and satisfaction with catheter-free pH monitoring are high in patients who had previously failed C-pH; catheter-free pH monitoring assists the definitive diagnosis of GERD in this group. [ABSTRACT FROM AUTHOR]

Oesophageal spasm presents with dysphagia and chest pain. Current treatments are limited by poor efficacy and side effects. Studies in health and oesophageal dysmotility show that sildenafil reduces peristaltic pressure and velocity; however the clinical efficacy and tolerability in symptomatic oesophageal spasm remains uncertain. We provided open-label sildenafil treatment to two patients with severe, treatment resistant symptoms associated with oesophageal spasm. The effects of sildenafil on oesophageal function and symptoms were documented by high resolution manometry (HRM). Patients were followed up to assess the efficacy of maintenance treatment with sildenafil b.i.d. HRM revealed focal and diffuse spasm in the smooth muscle oesophagus that were associated with symptoms in both cases, especially on swallowing solids. Lower oesophageal sphincter function was normal. A therapeutic trial of 25–50 mg sildenafil suppressed oesophageal contraction almost completely for water swallows; however effective, coordinated peristalsis returned with reduced frequency of spasm for solid swallows. Dysphagia and chest pain resolved during the therapeutic trial and efficacy was maintained on maintenance treatment with 25–50 mg sildenafil b.i.d. without troublesome side effects. This report shows that sildenafil can improve oesophageal function and relieve dysphagia and chest pain in patients with oesophageal spasm in whom other treatments have failed. [ABSTRACT FROM AUTHOR]

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Introduction Standard manometry studies diagnose oesophageal dysmotility in patients presenting with dysphagia on the basis of a small number of small volume water swallows. The association of symptoms with abnormal pressure events strongly support the clinical relevance of manometry findings; however, patients report symptoms infrequently with 5–10 ml water swallows. Solid swallows and normal eating behaviour have not entered clinical practice because of the difficulty interpreting the complex pressure events and a lack of control values. The aim of this study was to assess the prevalence of symptomatic oesophageal dysfunction following individual liquid and solid bolus swallows and a standardised test meal in patients presenting with dysphagia and asymptomatic volunteers Methods 30 consecutive patients referred for investigation of endoscopy negative dysphagia and 23 healthy volunteers underwent HRM (Manoscan 360°, SSI) with 10 × 5 ml water and 5 × 1 cc bread swallows in the upright seated position. A test meal (cheese and onion pie: 500 Kcal, 34 g fat) was provided if patients consented and for 10 healthy volunteers Results Water and bread swallows were successful in 29/30 patients (12 M:18 F, age 16–86) and all healthy volunteers (11 M:12 F, age 20–56). 10 patients and 10 volunteers completed the test meal. No healthy subject had clinically significant dysmotility or complained of symptoms. 2/29 (7%) patients experienced their typical symptoms with water, 13/29 (45%) with bread (p = 0.023), 8/10 (80%) with the meal and 16/29 (55%) when results of bread and meal were combined (p = 0.008 compared to water swallows). A change in HRM diagnosis was made in 8/29 (28%) patients on the basis of solid compared to water swallows, of whom 5 (17%) complained of typical symptoms. When a meal was provided, there was a change in HRM findings in 7/10 patients compared to 5 ml water, of whom 4 complained of typical symptoms. When results were combined 10/29 (35%) showed a change in diagnosis and 5 had typical symptoms. Pathology that would have been missed with water swallows alone included: hypertensive contractility (2), spasm (2), variant achalasia (1) and increased resistance to flow at the gastro-oesophageal junction (3). The clinical relevance of 5/8 (62.5%) of these was confirmed with typical symptoms coincident with abnormal pressure events. Two patients with asymptomatic hypotensive dysmotility with water showed normalisation with solid swallows Conclusion The diagnostic yield and ability to associate symptoms with oesophageal dysfunction is increased with inclusion of solid swallows and a test meal compared to water swallows alone in patients with endoscopy-negative dysphagia [ABSTRACT FROM PUBLISHER]

Introduction Previous studies suggest that prolonged ambulatory reflux monitoring can improve measurement consistency; however, previous reports were not analysed appropriately or adequately powered to determine the impact on key clinical parameters. The aim of this study was to assess measurement consistency for acid exposure time (AET) and symptom association with reflux events used to establish the diagnosis of GORD. Methods Acid reflux (pH) and symptom data were acquired by prolonged, 4 day, wireless pH recording (Bravo, Given Imaging). 163 consecutive patients presenting with predominantly typical reflux symptoms (heartburn, regurgitation) studied 2006–2009 with a record duration of >3.7 days were studied (636 days). Data were exported in XML format, redundant symptom markers were removed in one pass with reflux detection. A cross-validation procedure assessed measurement variability (standard deviation (SD)) and diagnostic consistency of AET, symptom index (SI) and symptom association probability (SAP). The 4-day records were divided into 1-day sections and re-assembled as all possible subsets. Index parameters were computed for all subsets and labelled with a sequence identifier in the database. Bias due to self-referential comparisons was excluded (i.e., day 1 was not compared with day 123) and, also, no comparisons with 4-day results are given. Standard diagnostic thresholds were applied. In addition, the effect of varying threshold pH value used for reflux detection on diagnostic consistency was assessed. Results Measurement variability: There was no change in AET or SI over time; however, SAP increased progressively with study duration. Standard deviation (SD) was higher for 1-day than 3-day records for AET (+50% (confidence interval (CI): 10%…120%)) and SI (+100% (CI 120%…270%)) with no important difference across the observed range. Results for 2 days were intermediate. Similar findings were present for SAP (1 day vs 3 days at 95% SAP (+100% (CI 10%…700%); however, for this parameter measurement variability increased exponentially as SAP approached 100%. Diagnosis: Consistency for GORD diagnosis increased with study duration () for all parameters studied. OC-048 Effect of study duration on test sensitivity and specificity Conclusion Increasing the duration of reflux studies progressively improves diagnostic consistency for GORD based on both AET and reflux-symptom association analysis independent of diagnostic threshold applied. [ABSTRACT FROM PUBLISHER]

Introduction Gastro-oesophageal reflux disease (GORD) generally presents as pathological Upright, Supine or Bi-positional reflux. Hiatus hernia (HH) and dysmotility are common in chronic GORD. However, in the presence of HH, it is unclear how age, severity of oesophageal acid exposure and dysmotility are related to the different postural types of GORD. Methods From March 2006 to July 2010, 1242 patients with GORD symptoms had high resolution manometry (HRM; Manoscan 360, Sierra) and 24-h catheter-based pH-monitoring (Slimline™, Medtronic) performed. 124 consecutive patients with both pathologic reflux and HH were collected. Patients were classified as Upright (n = 24), Supine (n = 38) or Bi-positional (n = 62) predominant reflux. Total (TR > 4.2%), upright (UR > 8.15%) and supine (SR > 3.45%) reflux parameters were used to classify GORD into position subtypes. HH was defined as Type II (lower oesophageal sphincter (LOS)-crural diaphragm (CD), 1–2 cm) and Type III (LOS-CD > 2 cm) in accordance with the Chicago Classification. Student's t test, χ tests and Mann–Whitney-U test were used for statistical analysis. Results Mean ±SD age was 54 ± 14 years (range 16–85 years; 64 males). Patients with Bi-positional reflux (57 years) were older than those with Supine (49 years) (p = 0.013) or Upright reflux (53 years) (p = 0.04). Furthermore the severity of oesophageal acid exposure (TR, UR and SR) was greater in the Bi-positional (18.1%, 17.6%, 19.7%) than Supine (8.6%, 4.8%, 14.8%) (p < 0.001) or Upright (8.5%, 12.8%, 1.1%) (p < 0.001) reflux group. Total supine reflux episodes in the Supine group were fewer in number (54) compared to the total upright reflux episodes in the Upright group (127) (p < 0.001), although the total reflux time was similar in both positions (124 min supine vs 127 min upright; p = NS). Although there was no significant difference in the mean peristaltic wave contractility and velocity between the three groups, the % of successful peristalsis was higher in the Upright (65%) than Supine (54%) or Bi-positional (52%) GORD group (p = 0.008 and p = 0.001, respectively). Patients with Type III HH were older (mean age 57 years; n = 71) than Type II HH (mean age 50 years; n = 53) (p = 0.013). There was no difference in HH length between the GORD position subtypes (range 2.0–8.4 cm). Although there was no difference in TR, UR and SR, the LOS basal pressure was lower in Type III (8.9 mmHg) than Type II (12.0 mmHg) HH patients (p = 0.05). Conclusion In patients with manometry-proven HH who present with symptoms suggestive of GORD, Bi-positional and Supine reflux predominance are associated with more severe disease and are more likely to be associated with failed peristalsis. Furthermore Bi-positional reflux disease is more common with increasing age as is Type III HH. [ABSTRACT FROM PUBLISHER]

Introduction Published reference values for oesophageal High Resolution Manometry (HRM) are available only for 5 ml water swallows in the supine position; however this is not representative of normal behaviour and rarely triggers symptoms. Analysis during and after eating a solid meal or drinking larger volumes is likely to increase the sensitivity of manometric studies to symptomatic oesophageal dysmotility and dysfunction. However this increases the complexity of pressure activity and, if it is to be applied in clinical practice, normal values for oesophageal motility and function are required. Methods 10 healthy volunteers (6M:4F, age 20–45) underwent HRM (Manoscan 360, SSI; 36 sensors). After baseline measurements of the oesophago-gastric junction (OGJ) and standard 5 ml water swallows, volunteers were observed eating a test meal (cheese and onion pie; 500 Kcal, 34 g fat) followed by drinking a 200 ml fruit-smoothie (9/10 subjects) and for 10 min afterwards. Physiologic measurements from HRM topographic plots focused on parameters that predict the success of solid bolus transport. Results No subject had hiatus hernia or primary oesophageal dysmotility. All completed liquid swallows and standard meal (consumption time median 6:15 min (range 3:30–13:30 min)). A mean of 1.5 pharyngeal swallows (range 1–3) was required to propel each mouthful into the oesophagus. 20 swallows (range 13–34) were required to ingest the meal of which 89% were successful, 3% were simultaneous (focal spasm) and 5% failed. The median (IQR) for intrabolus pressure (IBP) increased from 8.9 (6.7–13.8) mm Hg for 5 ml water to 18.9 (16.8–24.0) mm Hg for solid meal swallows (p<0.001). Normal values for key parameters are presented in the . PWE-130 A mean of 20 swallows (range 13–34) was required to drink the smoothie. Complete suppression of oesophageal contractility was achieved in 7/9 subjects. A powerful postcontraction was observed in 8/9 subjects. Apart from postprandial belching, no volunteer reported symptoms during or after the study. Conclusion Peristaltic coordination and pressure increased in response to resistance to bolus passage (raised IBP) with solid compared to liquid swallows. Complete oesophageal relaxation and LOS opening was observed on free drinking. Reference values for future studies are presented to assess the clinical utility of including a standardised meal and free drinking in HRM investigation of patients with oesophageal symptoms. [ABSTRACT FROM PUBLISHER]

Introduction Previous studies have shown that oesophageal contractility increases with workload (eg, swallowing solids); however mechanistic studies suggest that effective oesophageal clearance depends more on effective coordination between the proximal and distal peristaltic contractions at the proximal transition zone (PTZ) than contractile pressure per se. This study assessed the effects of bolus consistency and position change on coordination of oesophageal contractions as assessed by the PTZ physiology in healthy, asymptomatic volunteers using high resolution manometry (HRM). PWE-132 Methods 23 healthy volunteers (11M:12F, age 20–56) underwent HRM (Manoscan 360°, SSI) with 10×5 ml water and 21 with 5×1 cc bread swallows in the upright seated and supine positions. Measurements of the PTZ mean pressure and break in peristalsis length defined by 30 mm Hg isocontour were recorded. In addition, the length of the proximal contraction (upper oesophageal sphincter to start of PTZ) and distal contraction (end of PTZ to lower oesophageal sphincter) defined by 30 mm Hg isocontour and normalised to oesophageal length (%) were calculated. Results PTZ mean pressure increased from liquid to solid in the upright (12.3 (8.3–17.8) vs 20.3 (12.9–29.5) mm Hg; p<0.001) and supine (15.1 (10.9–25.1) vs 34.0 (19.1–51.3) mm Hg positions; p<0.001). PTZ length decreased from liquid to solid in the upright (3.2 (1.9–7.4) vs 0.5 (0–2.5) cm; p<0.001) and supine (2.9 (1.1–4.5) vs (0.0 (0.0–2.3) cm; p=0.002) positions. These effects remained significant when corrected for oesophageal length. Proximal peristaltic contraction length was not affected by changes in viscosity (p=NS) or position (p=NS); however distal peristaltic contraction length increased with bolus consistency in the upright (p=0.004) and supine (p=0.016) positions, and on moving from the upright to the supine position for liquid (p<0.001) and solid (p=0.013). Conclusion Increased bolus consistency and position change from upright to supine position both increase the coordination of peristaltic contraction in healthy subjects. This effect is achieved by promoting contractility in the distal segment. This response to ‘physiologic challenge’ may increase specificity of manometric studies and provide a useful test of the oesophagus' ability to adapt to increased workload (eg, after fundoplication). [ABSTRACT FROM PUBLISHER]

Introduction High Resolution Manometry (HRM) with presentation of pressure data as spatiotemporal plots highlights oesophageal landmarks and contractions that facilitates data analysis and interpretation. Normal values have been published for water swallows in the supine position. Studies in the upright position and with solid swallows reproduce more normal swallowing behaviour and increase test sensitivity for symptomatic dysmotility and dysfunction; however these ‘physiologic challenge swallows’ increase the complexity of pressure activity which may impair interinvestigator agreement. The aim of this study is to assess the interobserver agreement of water and solid swallows in the upright and supine positions for HRM. Methods 12 healthy volunteers (Male:Female 5:7, age 28–56) underwent HRM using a 36 channel solid state assembly (Manoscan 360; Sierra Scientific Instruments) with sensors spaced at 10 mm intervals from the pharynx to the stomach. After baseline measurements of the oesophago-gastric junction, assessment with 5×5 ml water and 3×1 cc bread swallows were assessed in the upright and supine position. Spatiotemporal plots of upright swallows were assessed by 3 investigators and supine swallows were analysed by 2 investigators. The intraclass correlation coefficient (ICC) was used to assess agreement for continuous variables corrected for chance. An ICC of <0.2 implies little, >0.5 good and >0.80 almost perfect agreement. Results In the supine position ICC between two raters was >0.8 for all parameters for liquids and solids. In the upright position the ICC between three raters was significant and >0.5 for all parameters measured using liquid and solid swallows except for velocity (). PWE-129 Conclusion There is a high rate of agreement between observers for key HRM parameters during liquid and solid swallows. Interobserver agreement for velocity and, to a lesser extent, other parameters was lower in the upright than the supine positions likely due to reduced contractile pressures and coordination in the physiologic position. [ABSTRACT FROM PUBLISHER]

Introduction High resolution manometry (HRM) with spatiotemporal presentation of pressure data provides a detailed representation of oesophageal anatomy, motility and function. In the pharynx, raised Intrabolus pressure (IBP) with a steep intrabolus pressure gradient on HRM identifies clinically significant resistance to flow in the region of the upper oesophageal sphincter. The same principle can be applied to identify pathology that obstructs bolus passage also in the oesophagus and lower oesophageal sphincter (LOS); however larger volumes are required due to the greater capacity of the distal oesophagus. The sensitivity of this test to detect pathology may be increased by ingestion of high viscosity fluids compared to water; however normal values for these tests have not been established. The aim of this study was to compare oesophageal function with 200 ml high viscosity versus low viscosity liquid swallows in the physiologic, upright seated, position. Methods 9 healthy subjects (Male:Female 5:4, age 20–44) underwent HRM using a 36 channel solid state assembly (Manoscan 360, Sierra Scientific Instruments). After standard 10×5 ml water swallows, 200 ml of water (viscosity 1 cPois) and 200 ml of a thick lactose-free fruit-smoothie (100 kcal, ∼100 cPois) were ingested in consecutive order. Volunteers were asked to drink the liquid through a straw without stopping. Spatiotemporal plots of 5 ml water and large volume multiple swallows were assessed. Results are presented as Median (IQR). χ test was used for qualitative analysis and Wilcoxon test was used to for non-parametric quantitative group comparisons. Results A similar number of swallows were required to drink the high and low viscosity liquid (19.9 vs 17.9; p=0.4); however the duration required to ingest the smoothie was greater (35 s (33–49 s) vs 25 s (22–30 s; p=0.018). Complete suppression of oesophageal contractility was achieved for all water and 7/9 fruit-smoothie swallows. IBP was somewhat higher for 5 ml water swallows (8.9 mm Hg (6.7–13.8 mm Hg)) compared to 200 ml water (3.6 mm Hg (2.5–4.6)) and 200 ml smoothie (3.0 mm Hg (0.0–4.4 mm Hg)), although this difference was non-significant (p=0.109 and 0.139 respectively). A powerful postcontraction was observed in most patients after drinking the smoothie and water (8 vs 5/9 patients; p=0.294) followed by an increase in LOS postcontraction pressure (12.7 vs 7.1 mm Hg; p=0.144) respectively. Conclusion This study compares the function of the healthy oesophagus to free drinking of low versus high viscosity fluids. Furthermore it provides reference values for future clinical studies to assess the clinical utility of including high viscosity fluids in HRM investigation of patients with oesophageal symptoms. [ABSTRACT FROM PUBLISHER]

Introduction Manometry is applied in patients with suspected gastro-oesophageal reflux disease (GORD) to exclude motility disorders as a cause of symptoms. Routine studies use a small number of small volume water swallows, however dysmotility and symptoms are more likely to occur with normal eating behaviour. This approach has not entered clinical practice because of difficulty interpreting complex pressure events during ingestion of solids and a standardised meal as well as a lack of control values. This study aimed to assess the prevalence of symptomatic oesophageal dysfunction following individual liquid and solid bolus swallows and a standardised meal in patients with reflux symptoms and asymptomatic volunteers. Methods 45 consecutive patients with predominant reflux symptoms and 23 healthy volunteers underwent HRM (Manoscan 360°, SSI) with 10×5 ml water and 5×1 cc bread swallows in the upright seated position. A test meal (cheese and onion pie; 500 kcal, 34 g fat) was provided if patients consented. Ambulatory reflux studies were performed in patients. Results Water and bread swallows were completed in 44/45 patients (16 M:28 F, age 32–76) and all healthy volunteers (11 M:12 F, age 20–56). 18 patients and 10 volunteers completed the test meal. No healthy subject had clinically significant dysmotility or symptoms during the study. There were no symptoms with water swallows. 14/44 (32%) complained of symptoms with bread (p =0.0013), 7/18 during the meal and 16/44 (36%) when results of bread and meal were combined (p=0.0006). Bread swallows and a test meal resulted in a change of manometry diagnosis in 18/44 (41%) patients. In 13 patients dysmotility was present with solid but not water swallows: hypertensive contractility (3), oesophageal spasm (4), resistance at the gastro-oesophageal junction (4), variant achalasia (1) and severe peristaltic dysfunction (1). Conversely, normal peristalsis was seen in 5 asymptomatic patients with hypotensive motility on water swallows. Symptoms were associated with oesophageal dysfunction during the test meal in 7/16 (44%) patients: hypertensive contractility (1), oesophageal spasm (3), and resistance at the gastro-oesophageal junction (3). Ambulatory reflux studies were completed in 40/45 patients and 18/40 (45%) patients had an objective diagnosis of GORD. A new diagnoses based on symptomatic dysmotility was present in 1/18 (6%) patients with GORD, and 6/22 (27%) patients without GORD (p=0.016). Conclusion The inclusion of solid swallows and a test meal increased the diagnostic yield of HRM in patients referred for investigation of reflux symptoms compared to standard water swallows, in particular, in the patient group without GORD on reflux studies. [ABSTRACT FROM PUBLISHER]

Introduction Laryngopharyngeal reflux (LPR) of gastric contents is a cause of chronic cough; however the pathophysiology of this disease remains unclear. Conventional manometry has insufficient spatial resolution for the functional assessment of the pharynx, upper oesophageal sphincter (UOS) and coordination between the proximal and distal oesophageal contractions that clear refluxate from the laryngopharynx and proximal oesophagus. This study applied high resolution manometry (HRM) in patients with chronic cough with and without association to reflux events. Methods Consecutive patients referred for investigation of chronic cough in 2009 were reviewed. Patients with hiatus hernia, severe co-morbidity and previous oeosphageal surgery were excluded. Of 66 patients referred, 34 (52%) (21 F:13 M) were eligible. HRM (ManoScan 360, Sierra) with detailed analysis (ManoView 2.0, Sierra) of 10 water swallows was performed followed by 24-h ambulatory pH-monitoring. Of this group 21 patients had negative reflux-cough symptom association probability (SAP; group A) and 13 had positive SAP (group B). Results from 23 healthy controls were available for comparison. A secondary analysis to assess the association of gastro-oeosphageal reflux (GOR) disease and motility was performed. Results Mean patient age was 55±15 (19–77). Mean acid exposure time was similar in group A and B (4.9±6.5 vs 3.7±4.0; p=0.34) and a similar proportion had pathologic reflux >4.2% acid exposure/24 h (7/21, 4/13; p=0.198). Moreover there was no significant interaction between the presence of GOR on pH-monitoring and any measurement of pharyngeal or oesophageal motility in this population. There was no significant differences for baseline UOS pressure; however residual UOS intrabolus pressure on 5 ml water swallows was higher in group A and B than controls (−0.34±0.69 and 1.09±0.64 mm Hg vs −4.4±5.8 mm Hg; p<0.018 and p<0.005 respectively). The percentage of primary peristaltic contractions was lower in group B with reflux associated cough than groups A and C (56% vs 79% and 87%; p=0.03 and p<0.002 respectively). Other motility parameters including pharyngeal contraction, peristaltic coordination and LOS function were similar in all groups. Conclusion Detailed analysis of swallowing and oesophageal motility by HRM revealed changes to UOS and oesophageal function that impair clearance from the pharynx and oesophagus in patients with cough compared to healthy controls. These changes were most marked in patients in whom cough was associated to reflux events. These findings suggest that not only GOR but also impaired clearance of luminal contents from the pharynx and proximal oesophagus contribute to chronic cough. [ABSTRACT FROM PUBLISHER]

Introduction The diagnosis of gastro-oesophageal reflux disease (GORD) by ambulatory reflux monitoring is based on oesophageal acid exposure time (AET) or temporal association of reflux events with patient symptoms. Several key issues required for reflux-symptom association, such as the most appropriate pH threshold and time window, have not been defined and current statistical analysis has important limitations: Symptom Index (SI) is a measure of an effect size, not of confidence. Symptom Association Probability (SAP) is a measure of confidence but not of size and applies the Fisher exact test inappropriately (dividing time into fixed intervals does not produce independent counts). This study presents a systematic assessment of symptom association in ambulatory gastro-oesophageal reflux monitoring data. Methods Acid reflux (pH) and symptom data were acquired by wireless pH recording (Bravo, Given Imaging). 163 consecutive patients presenting with predominantly typical reflux symptoms (heartburn, regurgitation) studied 2006–2009 with duration >3.7 days were studied (636 days). Data were exported in XML format, and analyzed by custom written program. A systematic analysis was performed. Results (1) Symptom markers A finite-state algorithm was developed to equalise patient responses, removing redundant markers in one pass with reflux detection. (2) pH threshold: Setting pH thresholds for reflux detection is not physiological and a weighted S-shaped (‘dose response') curve could be more appropriate. This was assessed varying the centre and steepness of the curve to maximise association with SI and SAP. A steep S-curve almost indistinguishable to a threshold was found: maximum correlation SI pH threshold 4.5, correlation 0.55; SAP pH threshold 4.4, correlation 0.34. (3) time window: The frequency of reflux associated symptom markers was above baseline only during minute 1. The association in minute 2 was no higher than chance. (4) Over time (day 1–4) SI was stable; however SAP increased progressively. Both parameters increased with the frequency of reflux events. CI for SI were computed by assuming a binomial distribution (Agresti-Coull method). Conclusion A novel approach to symptom association of ambulatory reflux monitoring data is presented. Confounding due to redundant symptom markers is removed by a finite-state algorithm. Acid threshold of pH 4.5 and a time window of 1 min provided optimal correlation with SI. Computing SI with CI provides a statistically valid, single parameter that describes both size of effect and likelihood of association between reflux events and symptoms. [ABSTRACT FROM PUBLISHER]