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INTRODUCTION: Esophagogastric junction outflow obstruction (EGJOO) defined on high-resolution esophageal manometry (HRM) poses a management dilemma given marked variability in clinical manifestations. We hypothesized that findings from provocative testing (rapid drink challenge and solid swallows) could determine the clinical relevance of EGJOO. METHODS: In a retrospective cohort study, we included consecutive subjects between May 2016 and January 2020 with EGJOO. Standard HRM with 5-mL water swallows was followed by provocative testing. Barium esophagography findings were obtained. Cases with structural obstruction were separated from functional EGJOO, with the latter categorized as symptom-positive or symptom-negative. Only symptom-positive subjects were considered for achalasia-type therapies. Sensitivity and specificity for clinically relevant EGJOO during 5-mL water swallows, provocative testing, and barium were calculated. RESULTS: Of the 121 EGJOO cases, 76% had dysphagia and 25% had holdup on barium. Ninety-seven cases (84%) were defined as functional EGJOO. Symptom-positive EGJOO subjects were more likely to demonstrate abnormal motility and pressurization patterns and to reproduce symptoms during provocative testing, but not with 5-mL water swallows. Twenty-nine (30%) functional EGJOO subjects underwent achalasia-type therapy, with symptomatic response in 26 (90%). Forty-eight (49%) functional EGJOO cases were managed conservatively, with symptom remission in 78%. Although specificity was similar, provocative testing demonstrated superior sensitivity in identifying treatment responders from spontaneously remitting EGJOO (85%) compared with both 5-mL water swallows (54%; P < 0.01) and barium esophagography (54%; P = 0.02). DISCUSSION: Provocative testing during HRM is highly accurate in identifying clinically relevant EGJOO that benefits from therapy and should be routinely performed as part of the manometric protocol.

Introduction The Lyon Consensus 2018 describes nocturnal baseline impedance (MNBI) as a reflection of oesophageal mucosa permeability, with lower values found in erosive than non-erosive reflux disease (NERD); however it is not clear how MNBI correlates with symptoms. This study aims to determine the relationship of MNBI across three common presentations of reflux; Barrett’s oesophagus, NERD and functional heartburn (FH). Methods Between 2014 and 2020, pH-Impedance measurements and symptom index (SI) were collected for 37 consecutive patients with at least 3 cm of Barrett’s oesophagus (13 on and 24 off proton pump inhibitors; PPI). 37 consecutive patients with NERD and 37 with FH were also included for comparison. MNBI was calculated from sensors at 3 and 5 cm above the LOS over 3 × 10 minute intervals during the nocturnal period. Results There was a significant difference in median acid exposure time (AET) between the 3 subgroups; Barrett’s (14.0%(6.3%,23.5%), NERD (8.9%(5.6%13.5%) and FH (1.9(0.7%, 2.7%) (p MNBI was low in Barrett’s compared to NERD and FH (figure 1; p 3 cm) Barrett’s who had attempts at therapy (ablation, mucosal resection) compared to the 27 who had not received therapy (p=0.96). There was a moderately inverse correlation between Barrett’s segment length (median 5 cm (3 cm,9 cm) and MNBI (r = -0.436; p=0.038). Conclusion This study suggests that the impact of reflux disease on mucosal permeability (MNBI) may have an influence on symptom perception. Both MNBI and symptom perception were significantly reduced in Barrett’s compared to NERD. Furthermore, neither MNBI nor symptom perception are affected by use of acid reducing medication despite the difference in AET. This study provides further validation to the Lyon consensus definition of MNBI as a measure of reflux disease severity.

BACKGROUND: Fecal incontinence is a debilitating and highly prevalent problem among multiple sclerosis patients. Conservative therapies often fail to provide benefit. Posterior tibial nerve stimulation is a minimally invasive neuromodulatory therapy with proven efficacy for fecal incontinence in non-neurological settings. OBJECTIVE: To evaluate the efficacy of posterior tibial nerve stimulation in treating multiple sclerosis-related fecal incontinence. METHODS: Consecutive multiple sclerosis patients with fecal incontinence that had failed conservative therapy received posterior tibial nerve stimulation between 2012 and 2015. All patients had previously undergone anorectal physiology tests and endoanal ultrasound. Patients whose Wexner incontinence score reduced below 10 post-therapy or halved from baseline were deemed responders. RESULTS: Thirty-three patients (25 female, median age 43 years) were included. Twenty-three (70%) had urge, 4 (12%) passive, and 9 (27%) mixed fecal incontinence. Twenty-six (79%) were classified as responders. The majority of subjects had relapsing-remitting multiple sclerosis (67%); those had a significantly higher response rate (95% vs. 67% and 50% in primary and secondary progressive respectively, P

OBJECTIVE: The symptoms of fecal incontinence and constipation can arise from a variety of alterations of anorectal function. The aim of this study was to investigate components of the anorecal reflex in patients with these symptoms, to determine the functional significance of the various physiological parameters. METHODS: 21 healthy volunteers (controls), 78 incontinent and 74 constipated patients were recruited and symptom burden determined using the Wexner incontinence and constipation questionnaires. All participants underwent standardised anorectal physiology including anorectal manometry, anorectal distension and electrosensitivity thresholds, rectal mucosal blood flow and rectoanal inhibitory reflex measurement. RESULTS: Patients with passive incontinence had lower resting sphincter pressures than controls (38 vs 87cmH2 O, p

Introduction The Lyon Consensus 2018 recommends at least 3 symptoms for reliable symptom association analysis; however it is not clear if symptoms should be combined or analysed individually. This study aims to determine the impact of calculating symptom index (SI) as a measure of symptom association in combination or separately. Methods SI measurements were collected for 139 consecutive patients who presented with reflux symptoms and received ambulatory pH monitoring at a tertiary referral centre in London. Typical symptoms were defined as heartburn (HB) and regurgitation; atypical symptoms included chest pain, belch, laryngopharyngeal reflux and others (e.g. cough). A positive SI (SI+) was considered when ≥50% of symptom events were preceded by a reflux episode within a 2 minute window. Results are presented as median (IQR; interquartile ratio). Comparisons were made using the Wilcoxon Signed Rank t-test. Results All but one patient reported at least 3 combined symptoms. The remaining 138 patients (mean age 49 yrs; 35 males) reported a median of 30 (14, 68) symptoms overall. With all presenting symptoms combined, 13 (9.4%) patients exhibited SI+, median 73% (61%, 77%). The remaining 125 patients were SI-, median 13% (0%, 25%). When calculating symptoms individually, 25 further patients were identified with SI+ (n=38; 27.5%), thus increasing the diagnostic yield for SI+ by 3-fold; median 69% (50.5%, 99%) (p When typical symptoms were combined (HB + regurgitation), 12 further SI+ patients were identified (n=25; 18.1%), median 68% (50%, 81%) (p Compared to analysing all symptom together, a change in diagnosis (from SI+ to SI− or vice versa) was seen in 26 (18.8%), when symptoms were analysed separately; particularly for HB (n=12; 8.7%), combined typical symptoms (n=28; 20.3%) and combined atypical symptoms (n=20; 14.5%). Increasing the threshold for inclusion from ≥3 to ≥6 symptoms resulted in the elimination of 10 patients and led to a greater likelihood for detecting SI+ for HB (n=23; 18.0%), typical symptoms (n=23; 18.0%) and atypical symptoms (n=15, 11.7%) compared to combining all symptoms together. Conclusions Diagnostic yield of symptom-association analysis increases (up to 3-fold) when symptoms are analysed individually than when all symptoms are combined, likely because it focuses on the most relevant symptoms that the patient complains of.

Introduction The Lyon Consensus 2018 describes mean nocturnal baseline impedance (MNBI) as a possible measure of oesophageal mucosa permeability, with lower values associated with damage; however MNBI has not yet entered routine clinical practice. This study aims to determine the relationship of MNBI across three common presentations of reflux; Barrett’s oesophagus, NERD and functional heartburn (FH). Methods Standard pH-Impedance measurements as well as symptom index (SI) were acquired for all patients. The impedance channel at 3 cm was used to calculate MNBI by averaging 3 nocturnal 10 minute intervals 1 hr apart. Consecutive tracings between 2014 and 2016 for 3 reflux subgroups were analysed; 22 Barrett’s Oesophagus (13 on proton pump inhibitors; PPI), 26 NERD and 26 FH. Results are presented as median (IQR; interquartile ratio). Comparisons were made using Kruskall-Wallace test and Mann-Whitney U test as appropriate. Correlations were performed using Spearman’s correlation coefficient. Results There was no significant difference in total reflux (TR) between patients with Barrett’s (median TR 11.2% (2.5%, 18.7%) and NERD (8.1% (5.5%, 12.9%) (p=0.497). The difference with FH (TR 22% (12%, 34%) is defined by the entry criteria (p There was no statistically significant difference in MNBI between Barrett’s while on or off PPIs (p=0.556). There was also no difference in MNBI between 9 patients with persistent Barrett’s who had attempts at ablation therapy compared to the 13 who had not (p=0.96). Using the Kruskall-Wallace test, there was a significant difference observed in MNBI between all 3 categories of reflux (p There was a moderately inverse correlation between Barrett’s segment length (median 6 cm (3 cm, 10 cm) and MNBI (r= −0.436; p=0.038). Conclusion In keeping with the published literature, this study shows that severity of reflux disease, as measured by ambulatory pH-impedance monitoring, was not dissimilar between Barrett’s oesophagus and NERD, while symptom burden was greater in NERD. On the other hand, MNBI can differentiate between the disease states despite the reduced symptom burden. Also, it correlates with the degree of mucosal damage associated with Barrett’s regardless of PPI use or previous therapy. MNBI may be a better marker of reflux disease severity than standard pH measurements.

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

Background Most patients with multiple sclerosis report bowel symptoms, but the underlying pathophysiology is unclear. Objective We hypothesize that rectal dysfunction in multiple sclerosis is secondary to involvement of the spinal cord by the disease and that this can be measured by assessing rectal compliance. Design This was a case-control study. Settings The study took place in a neurogastroenterology clinic and tertiary referral center. Patients Forty-five patients with multiple sclerosis, 19 with a spinal cord injury above T5, and 25 normal control subjects were included in this study. Patients with multiple sclerosis were subdivided into 2 groups according to the Expanded Disability Status Scale, below 5 (multiple sclerosis minor disability, n = 25) or above 5 (multiple sclerosis major disability, n = 20), as a reflection of spinal cord involvement. Main outcome measures Rectal compliance, Wexner constipation, and Wexner incontinence scores were measured. Results Data are presented as mean and SD. Expanded Disability Status Scale correlated with rectal compliance but not with Wexner constipation or Wexner incontinence scores. Post hoc analysis showed no significant difference in Wexner constipation and Wexner incontinence between the 2 multiple sclerosis groups. Limitations Limitations to this study include the lack of an asymptomatic group with multiple sclerosis and the small sample size to evaluate bowel symptoms. Conclusions Rectal compliance correlates with disability, and observed alterations in the rectal properties are secondary to spinal cord involvement. Our findings suggest that, in patients with neurologic impairment, rectal compliance is a surrogate of reflex activity of the spinal cord regulating rectal function and both a potential predictor of outcome and target for treatment. Multiple sclerosis patient subgroups had similar symptom burden, arguing that bowel dysfunction is multifactorial.

BACKGROUND Achalasia diagnosis requires elevated integrated relaxation pressure (IRP; manometric marker of lower esophageal sphincter [LES] relaxation). Yet, some patients exhibit clinical features of achalasia despite normal IRP and have LES dysfunction demonstrable by other means. We hypothesized these patients to exhibit equivalent therapeutic response compared to standard achalasia patients. METHODS Symptomatic achalasia-like cases, despite normal IRP, displayed evidence of impaired LES relaxation using rapid drink challenge (RDC), solid swallows during high-resolution manometry, and/or barium esophagogram; were treated with achalasia therapies and compared to standard achalasia patients with raised IRP. Outcomes included equivalence for short- and long-term symptom response and stasis on barium esophagogram. KEY RESULTS Twenty-nine normal IRP achalasia cases (14 males, median age 50 year, median Eckardt 6, barium stasis 12 ± 7 cm) and 29 consecutive standard achalasia controls underwent therapy. Among cases, LES dysfunction was most often identified by RDC and/or barium esophagogram. Short-term symptomatic success was equivalent in cases vs controls (90% vs 93%; 95% CI for difference: -19% to 13%). Median short-term (1 vs 1; 95% CI for difference: 0-1) and long-term Eckardt scores (2 vs 1; 95% CI for difference: 0-2) were similar in cases and controls, respectively. Adequate clearance was observed in 67% of cases vs 81% of controls on post-therapy esophagogram. CONCLUSIONS AND INFERENCES We described a subset of achalasia patients with normal IRP, but impaired LES relaxation identifiable only on additional provocative tests. These patients benefited from treatment, suggesting that such tests should be performed to increase the number of clinically relevant diagnoses.

Introduction: Maximising radiotherapy dosage is associated with better tumour response in prostate cancer. High dose three-dimensional conformal radiotherapy (3D CRT) has allowed dose escalation to be safely achieved and the current standard dose in the UK with this technique is 74 Grays (Gy). Documenting normal tissue tolerance is critical and forms the basis of this prospective study of anorectal toxicity. Patients and methods: Seventeen consecutive men (median age 72 (range 50–79) years) with localised or locally advanced prostate cancer treated with 74 Gy of 3D CRT were studied. Wexner incontinence scores, comprehensive anorectal physiology and endoanal ultrasound were measured before and four months after completing treatment. Results: Wexner incontinence scores increased from a median of 0 to 1 (range 0–6) with treatment ( p=0.001). Patients developed faecal urgency (7/17), passive faecal loss (5/17) or a combination of both (3/17) as new anorectal symptoms. No patients reported episodes of frank faecal incontinence. A significant decline in rectal mucosal electrosensitivity (mean (standard deviation (SD)) thresholds increasing from 24.7 (10.7) to 34.3 (9.3) mA after treatment, p=0.003) and an increase in rectal elastance (mean (SD) of 0.056 (0.03) mm Hg/ml to 0.078 (0.036) mm Hg/ml pre- and post-treatment respectively, p=0.0181) was seen. No changes in anal canal manometry, rectal distension volumes and endoanal ultrasound were noted. Conclusions: Early anorectal symptoms are common after 3D CRT for prostate cancer. Rectal injury is evident with an increase in wall stiffness and a decrease in mucosal sensitivity. Longer term studies monitoring anorectal toxicity are warranted.

Objectives Bowel and bladder symptoms are highly prevalent in patients with multiple sclerosis (MS). Bladder dysfunction (affecting 75% of these patients) is caused by disease in the spinal cord, whilst the pathophysiology of bowel dysfunction is unknown. Pathways regulating both the organs lie in close proximity to the spinal cord, and coexistence of their dysfunction might be the result of a common pathophysiology. If so, the prevalence of bladder symptoms should be greater in patients with MS and bowel symptoms. This hypothesis is tested in the study. We also evaluated how patient-reported symptoms quantify bowel dysfunction. Patients and methods The Neurogenic Bowel Dysfunction questionnaire and the presence of bladder symptoms were recorded in 71 patients with MS and bowel symptoms. Disability, a surrogate clinical measure of spinal cord disease, was assessed using the Expanded Disability Status Scale. Bowel and bladder symptoms were quantified by patient-reported frequency, expressed in time percentage (0, 25, 50, 75 or 100% of the time the symptom was perceived), and patient-reported severity on a visual analogue scale between 0 and 100. Results The prevalence of bladder symptoms was 85%, which is higher than that expected in an unselected population of patients with MS. Neurogenic Bowel Dysfunction score was significantly correlated with both patient-reported frequency (r=0.860, P

Fecal incontinence (FI) and constipation can arise from a variety of alterations of anorectal function. This study aimed to investigate the components of the anorecal reflex in patients with these symptoms and to determine the functional significance of various physiological parameters.Altogether 21 healthy volunteers (controls) and 78 FI-predominant and 74 constipation-predominant patients were recruited and administered Wexner incontinence and constipation questionnaires. All participants underwent standardized anorectal physiology assessments.Patients with passive FI had lower resting sphincter pressures than controls (38 cmHAnorectal motor, sensory and reflex abnormalities are seen in distinct patterns in patients with FI and constipation. This would suggest distinct physiological differences that may predict the potential for different neuromodulation treatment and behavioral modalities in these conditions.

Introduction Timed barium esophagram (TBE) is an objective measurement of esophageal emptying in achalasia. Post-therapy reduction of residual barium column height correlates imperfectly with short term symptomatic outcomes. We hypothesise that surface area (SA) of the barium column may be more accurate than height; firstly, by incorporating improvement in esophageal width that often occurs post-therapy, but also by correcting for artificially higher height values due to esophageal contraction occurring. We aimed to compare the correlation of TBE outcome measures of height and SA with symptom improvement post-therapy. Method Achalasia patients who underwent therapy between 2015–6 and had TBE and Eckardt score (ES) performed at baseline as well as within 6 months post-therapy were included. TBE images were acquired 5 mins following ingestion of 200 mL barium. Barium height was measured between the gastro-esophageal junction and the superior extent of any residual barium column. After manually defining column boundaries, software was used to calculate SA. Adequate symptom relief was defined as ES reduction to ≤3. On TBE, metrics of adequate emptying evaluated were i) post-therapy column height 50% reduction in column height from pre to post-therapy and iii)>50% reduction in column SA from pre to post-therapy. Results Of 18 patients, 11 had dilatation and 7 POEM. Reductions with therapy of both 5 min barium column height (14.7±8.7 to 7.9±6.0 cm; p=0.01) and SA (52.7±43.5 to 24.5±26.0cm2; p=0.02) were noted. Symptoms also improved; median baseline ES 7 (IQR 5.25–8) improved to 0 (IQR 0–1) post-therapy. However there was poor concordance between post-therapy barium height and symptomatic relief (i.e. post-therapy column >5 cm despite ES ≤3 or vice versa), and the correlation (R) between these two variables was poor. Similar poor concordance was seen when adequate emptying was defined by >50% reduction in column height, but >50% reduction in SA paralleled symptom relief most closely. Conclusion In TBE performed on achalasia patients post-therapy, reduction in SA of the residual barium column compared with baseline values parallels symptomatic relief more closely than reduction of column height. Disclosure of Interest None Declared

BACKGROUND Bowel symptoms are common in patients with multiple sclerosis, but current treatment is empirical. OBJECTIVE This study aimed to identify effect of biofeedback on bowel symptoms, mood, and anorectal physiology in patients with multiple sclerosis. DESIGN This was a prospective observational study: the amount of change between pre- and posttreatment values of outcome measures was compared and analyzed. Responders were considered to be patients who demonstrated an improvement greater than or equal to the 25th percentile of the change in bowel score. Comparison between responders and nonresponders was performed. SETTINGS This investigation was conducted at a neurogastroenterology clinic, tertiary referrals center. PATIENTS Thirty-nine patients with multiple sclerosis and constipation and/or fecal incontinence were included in the study. INTERVENTION Patients were given bowel biofeedback therapy. MAIN OUTCOME MEASURES The primary outcome measures were the Wexner Constipation and Wexner Incontinence scores. The secondary outcome measures were hospital anxiety and depression scores and anorectal physiology parameters. RESULTS Data are reported as median and interquartile ranges. After biofeedback there was significant improvement in Wexner Constipation (12 (5-19) pretreatment vs 8 (4-14) posttreatment, P = .001), Wexner Incontinence (12 (3-15) pretreatment vs 4 (2-10) posttreatment, P < .001) and hospital depression scores (7 (3-11) pretreatment vs 5 (3-10) posttreatment, P = .015). The 5-second endurance squeeze pressure was also improved (21 (11-54) mmHg pretreatment vs 43 (26-59) mmHg posttreatment, P = .001). Posttreatment change of Wexner Constipation was -2(-5/0), and of Wexner Incontinence was -3(-9/0) ("-" indicates improvement). Therefore, those patients who had a reduction of at least 5 points in the Wexner Constipation score and/or of at least 9 points in the Wexner Incontinence score were considered responders (18 patients, 46%). They showed a greater improvement of only 5-second endurance squeeze pressure (23.5 (7.5/32.75) mmHg responders vs 4 (-6/20) mmHg nonresponders, P = .008); no difference was observed in the comparison of baseline variables with nonresponders. Significant negative relationship existed between the change in the Wexner Constipation score (-2 (-5/0)) and the pretreatment Wexner Constipation score (12 (5/19), β = -0.463, P < .001), and the change in the Wexner Incontinence score (-3 (-9/0)) with the pretreatment Wexner Incontinence score (12 (3/15), β = -0.590, P < .001). So, the higher the initial bowel symptom score, the greater the improvement. LIMITATIONS This study was limited by the lack of a control group. CONCLUSIONS Biofeedback improves bowel symptoms, depression, and 5-second endurance squeeze pressure in patients with multiple sclerosis.

Aim Chronic constipation can be aetiopathogenically classified in to slow transit constipation (STC), rectal evacuation difficulty (RED) or a combination (BOTH). Although the efficacy of percutaneous tibial nerve stimulation (PTNS) in faecal incontinence has been well proven, a current literature search identifies only one study which assessed its effect on constipation. We aimed to evaluate the effectiveness of PTNS in patients with different causes of constipation. Method 34 patients (30 women, median age 50 (20-79) years with constipation who had previously failed maximal laxative and biofeedback therapy participated in the study. All patients underwent a baseline radio-opaque marker transit study and anorectal physiology. All had 12 sessions of PTNS of 30 minutes per session. A fall in the Wexner constipation score to ≤15 or by ≥5 points was taken as the primary outcome. Secondary outcomes included the results of pre- and post- PTNS transit and anorectal physiology studies. Results There were patients with 11 STC, 14 with RED and 9 with BOTH. A response was seen in four patients (1/11 STC, 2/14 RED and 1/9 BOTH). Comparing pre- and post- PTNS, there was no significant change in the mean Wexner score (p = 0.10). There was no change in colonic transit time among the whole population (p = 0.56) or among those with STC (p=0.47). There was no improvement in balloon expulsion in the whole group (p=0.73) or in patients with RED (p=0.69). Conclusion Percutaneous tibial nerve stimulation is of no benefit to patients with constipation, whatever aetiopathogenic mechanism is responsible for the symptoms. This article is protected by copyright. All rights reserved.

Introduction Resistance to bolus flow across the lower esophageal sphincter (LES) is a hallmark of achalasia. Presently the gold standard of diagnosis is by high-resolution manometry (HRM) demonstration of raised integrated relaxation pressure (IRP) following ten 5 mL water swallows; however, this does not replicate normal swallowing behaviour. It has been demonstrated that the addition of adjunctive tests improves sensitivity of identifying relevant dysmotility. Such tests include multiple water swallows (MWS; 200 mL water drunk freely) and solid swallows. In addition, the timed barium esophagram (TBE) measures esophageal emptying. This study describes a cohort of patients who have been treated as having achalasia based on resistance to flow not exhibited with single water swallows. Method Inclusion criteria were all patients between October 2014–2016 with normal mean and median IRP with 5 mL water swallows but considered to have achalasia due to resistance to flow demonstrated by pan-esophageal pressurisation (PEP) during MWS or solid swallows and/or a persistent column at 5 min during TBE. Outcome post-treatment was based on Eckardt score (ES). Results 14 patients (9 male) fulfilled inclusion criteria. 7 were treatment-naive and 7 treatment-experienced (3 myotomy, 4 dilatation). Mean resting LES pressure was 14.6±7.4 mmHg. In all patients, mean and median IRP values for ten 5 mL water swallows were non-raised (mean 9.1±4.3 and 8.7±4.5 mmHg respectively). Of the 7 treatment-naive patients, 5 demonstrated PEP on MWS, 3 on solid swallows and 6 had a positive TBE at 5 min. In treatment-experienced patients, 5 had PEP on MWS, 1 on solid swallows and all had a positive TBE. Of the 13 who had resistance to flow on TBE, 10 (77%) also had resistance demonstrated during MWS and/or solid swallows. Mean height of the 5 min column of barium at baseline was 16.5±8.9 cm. 8 patients underwent therapy based on these findings; one POEM and 7 pneumatic dilatations. Median baseline ES was 7.5 (IQR 5–8). Median ES at minimum 3 months following treatment was 1 (IQR 0–2.5; p Conclusion A normal IRP for water swallows does not preclude a diagnosis of achalasia. The addition of free drinking/solids during HRM or the TBE can identify pathology that might have been missed with standard 5 mL water swallows alone. Patients treated based on this algorithm exhibit excellent treatment outcomes, validating this approach. Disclosure of Interest None Declared

Introduction Traumatic vaginal delivery is closely correlated with attenuation of anorectal structure and function, and hence symptoms of faecal urgency (FU) and incontinence (FI). We aim to describe the immediate clinical and physiological effect of overt perineal trauma in patients within 6 months of injury. Methods One hundred consecutive postpartum (3–6 months) patients who sustained an obstetric tear at delivery were studied over a 13 month period. Mean age was 33 years (range 22–51 years old), 75 women were older than 30 years. All patients underwent anorectal physiology (ARP) and endoanal ultrasound (EAUS) as per Unit protocol. Results Cohort: 84 of these obstetric tears were first vaginal delivery; of 16 who were multiparous, 11 had also sustained tears in their first delivery. Ten women sustained a 2 nd degree tear, 84 a 3 rd degree tear (3 a=45; 3 b=33; 3 c=6) and 6 women a 4 th degree tear. Instrumentation was necessary in 55 of cases (43 forceps, 11 ventouse and 1 combination). Regarding other risk factors, birth weight was over 4 kg in 26 and 32 required an episiotomy. The table shows symptom burden at median 4 months; 60 patients were symptomatic, presenting with more than one troublesome symptom. Investigation: ARP demonstrated 17 with reduced resting sphincter pressure, 43 reduced voluntary squeeze and 27 inadequate endurance squeeze. Only 33 women had entirely normal manometry. Rectal hypersensitivity defined as two reduced thresholds to rectal mechanical distension was found in 11 patients. Similarly, abnormal anal and rectal electrosensory thresholds were seen in 20 and 5 women respectively. There was a significant correlation between those patients who had 3 rd degree tears and hypersensitivity to maximum balloon distension (p = 0.007) and reduced anal sensitivity (p = 0.005). Immediate post-partum repair is often unsuccessful, 56 women had a persistently disrupted or scarred external sphincter and 22 had a disrupted internal anal sphincter on EAUS. Conclusion Maternal age over 30 and first delivery are disproportionately correlated to the likelihood of severe obstetric tears. The majority of women experience symptoms, of which the commonest are FU, FI and flatus incontinence. Sphincter disruption is often persistent despite attempted repair, and is associated with rectal hypersensitivity. Systematic investigation and clinical assessment is recommended to improve clinical management and offer counselling in regards to risks associated with future deliveries. Disclosure of Interest None Declared

Introduction It is not clear if Barrett’s is a consequence of excessive reflux only or reduced clearance of refluxed materials. This study compares oesophageal reflux over 24 hours and High Resolution Manometry (HRM) response to solids in Barrett’s with non-Barrett’s reflux (NBR). Methods Reports for 19 consecutive patients (M58:F14) with ≥2 cm Barrett’s during 2015 were compared with 25 patients with NBR (M10:F16) and 13 patient controls with normal physiology/endoscopy (M3:F10). All had at least one typical symptom of heartburn, regurgitation or chest pain. All had HRM with the intention of completing 10x5cc water and 5x1cc bread. Contractile vigour was measured with the Distal Contractile Integral (amplitude x length x contraction time); DCI > 450 mmHg.cm.s and breaks in peristalsis of Results Lower oesophageal sphincter pressure was lower in Barrett’s (8 vs. 14 mmHg; p = 0.009). Compared to NBR, patients with Barrett’s (2–10 cm) had significantly reduced DCI for both 5 ml water (318 vs. 650 mmHg.cm.s; p = 0.007) and solid (1096 vs. 2002 mmHg.cm.s; p = 0.009). On the other hand, the likelihood of measuring a DCI of >450 was significantly reduced in Barrett’s only with solids (69% vs. 100%; p only for solids (44% vs. 65%; p = 0.029). All reflux parameters were similar between the two groups: total (p = 0.116), upright (p = 0.233) and supine reflux (p = 0.110), symptom index (p = 0.16), symptom association probability (p = 0.106) and total number of reflux events (p = 0.063). On the other hand, bolus clearance time (BCT) was significantly prolonged for Barrett’s (13 vs. 10 s; p = 0.009) solely due to prolonged supine BCT (14 vs. 10 s; p Comparing those with prior endoscopic Barrett’s therapy (n = 6) with treatment naive (n = 13), there was no difference in any motility or pH monitoring parameter apart from BET which was greater in those who received therapy (5.87% vs. 1.99%; p = 0.046). Conclusion Solids were superior to water swallows in demonstrating ineffective contractility in Barrett’s. This was associated with reduced nocturnal oesophageal clearance and increased exposure to refluxate during the day/night. These findings contribute to the theory of impaired contractility and reduced clearance despite acid-reducing medication in Barrett’s. Disclosure of Interest R. Sweis Conflict with: Organised Symposium funded by Given img/Diagmed, A. Raeburn: None Declared, E. Athanasakos: None Declared, N. Zarate-Lopez: None Declared, L. Lovat: None Declared, R. Haidry: None Declared, M. Banks: None Declared, A. Emmanuel: None Declared

Constipation and fecal incontinence affect 68% of patients with multiple sclerosis, but management is empirical. Transanal irrigation has been used successfully in patients with neurogenic bowel dysfunction.The aim of this study was to evaluate the effect of transanal irrigation on the bowel symptoms and general health status in these patients and the characteristics of those that had successful treatment and to obtain data for power calculations necessary for future randomized controlled studies.This was a prospective observational study in which pre- and posttreatment questionnaires (bowel symptoms and health status) were compared. Patients for whom treatment resulted in at least 50% improvement in bowel symptoms were considered responders. Baseline variables including anorectal physiology tests and rectal compliance were compared between responders and nonresponders.This study was conducted at a specialist neurogastroenterology clinic, tertiary referral center.Included were 30 patients who had multiple sclerosis and constipation, fecal incontinence, or both.Transanal irrigation was performed.The primary outcomes measured were the Wexner Constipation and Wexner Incontinence scores. The secondary outcomes was the SF-36 health survey. All scores were recorded before and after 6 weeks of treatment.At 6 weeks posttreatment, the Wexner Constipation score significantly improved (12 (8.75/16) pretreatment vs 8 (4/12.5) posttreatment, p = 0.001), as well as the Wexner Incontinence score (12 (4.75/16) pretreatment vs 4 (2/8) posttreatment, p0.001). The SF-36 score did not improve significantly (51.3 ± 7.8 pretreatment vs 50.4 ± 7.8 posttreatment, p = 0.051). Sixteen patients were responders and had higher baseline Wexner Incontinence scores (14 (11/20) responders vs 9 (4/15) nonresponders, p = 0.038) and SF-36 (53.9 ± 6.3 responders vs 47.9 ± 7.8 nonresponders, p = 0.027), as well as greater maximum tolerated volume to rectal balloon distension (310 (220/320) mL responders vs 168 (108/305) mL nonresponders, p = 0.017) and rectal compliance (15.2 (14.5/17.2) mL/mmHg responders vs 9.2 (7.2/15.3) mL/mmHg nonresponders, p = 0.019).This study was limited by its small sample size and the lack of control group with alternative treatment.Transanal irrigation is effective to treat bowel symptoms in patients with multiple sclerosis. Responders (53%) had higher baseline incontinence symptoms and better perception of their health, as well as a more capacious and compliant rectum.

Introduction Constipation affects up to 80% of spinal cord injury (SCI) patients and is cause of significant reduction of quality of life. Rectal compliance is determined by the rectal wall properties and by the supra-spinal modulation of the thoracic sympathetic and para-sympathetic lumbosacral efferents; it is increased in SCI patients with injury level above T5. Often this patient group has associated bladder dysfunction, and requires antimuscarinic agents (Tolterodine or Solifenacin), which are known to cause constipation. The authors aimed to assess the physiological effect of antimuscarinic agents on the anorectal function of patients with SCI above T5. Methods The authors prospectively collected data from 17 SCI patients (11 males, mean age 41, mean disease duration 13 months) attending a neuro-gastroenterology clinic at a tertiary centre. All had an established SCI above T5, and 11 had a complete injury. Anal manometry, assessment of rectoanal inhibitory reflex (RAIR) and rectal compliance were measured at baseline, and after antimuscarinic treatment was started (mean follow-up 12 weeks). Results Anal sphincter function parameters of squeeze and cough pressure were unchanged after antimuscarinic treatment (pre vs post 123±40 vs 122±36 p=0.827; 88±24 vs 87±26 p=0.859 respectively). However, resting anal pressure and rectal compliance were significantly raised after antimuscarinic treatment (82±18 vs 88±16 p=0.058; 19.2±5.0 vs 24.2±4.1 p Conclusion In SCI patients the use of antimuscarinic agents causes increased rectal compliance, reduced reflex relaxation of the anal sphincter and delayed latency of this reflex. These physiological changes all predispose towards constipation. In the absence of cortical modulation, in patients with a SCI level above T-5, sympathetic activity is effectively enhanced. The effect of these drugs underlines the importance of tonic parasympathetic input to rectal compliance and anorectal reflex function.

Introduction The gastrointestinal tract is affected in up to 90% of Systemic Sclerosis (SSc) patients with faecal incontinence (FI) being reported in up to 38%. Passive faecal incontinence secondary to internal anal sphincter atrophy is the characteristic finding. We have shown that neuropathic changes are implicated in SSc patients with FI and sacral nerve stimulation has emerged as a potentially beneficial therapy in SSc. However this is expensive, invasive, not widely available and we have shown that medium term efficacy is poor. Posterior tibial nerve stimulation (PTNS) is a potential alternative to modulate the sacral plexus indirectly, with none of these disadvantages. This is the preliminary data on a randomised placebo controlled trial of PTNS versus sham PTNS to determine if nerve modulation is an effective treatment in SSc associated FI. Methods We commenced a prospective randomised single-blind study of SSc patients with FI in February 2013 from a specialist Scleroderma unit. Baseline symptom scoring (bowel diary, Wexner), manometry and endoanal ultrasound were completed prior to randomization to PTNS or sham. PTNS was administered conventionally, by insertion of an acupuncture needle according to anatomical landmarks, connected to an electrical stimulator. Sham PTNS was administered in identical fashion but the PTNS surface electrode was not connected and instead separate TENS surface electrodes were connected to a TENS unit. Each patient underwent blinded intervention for 30 min periods, once a week for 12 weeks. The primary endpoints were the percentage reduction in faecal incontinence episodes and change in Wexner incontinence scores. Results A total of 13 SSc patients (11 f), mean age 61 (36–72) completed the trial by October 2013. Of these 6 (5 f) underwent PTNS and 7 (6 f) patients underwent sham stimulation. All PTNS patients showed a reduction (5–100%) in the number of FI episodes in comparison to 0 sham patients at 12 weeks (p Conclusion This pilot data is demonstrating significant effects of PTNS in Scleroderma-associated FI. We present this significant initial data but anticipate having at least 25 completed patients by May 2014. Disclosure of Interest None Declared.

Introduction Parkinson’s disease (PD) is a neuro-degenerative disorder with frequent involvement of the gut. Symptoms arise throughout the gastrointestinal tract through dysmotility secondary to autonomic and enteric nervous system involvement, as well from skeletal muscle involvement in the oropharynx and anorectum. It has been speculated that gut involvement may precede motor symptoms. The Wireless Motility Capsule (WMC) yields data on transit and motility throughout the gut. We report the first use of WMC to systematically assess motility in PD patients with and without gut symptoms, compared to controls. Methods 15 patients with established PD completed the study: eight (2 f, mean age 70 [47–85]) had GI symptoms and seven (2 f, mean age 61 [49–77]) did not based on history and baseline scores on the Gastroparesis Cardinal Symptom Index (GCSI) and Wexner constipation score. Data comparison with seven controls (3f, mean age 52 [39–63]). Medications affecting GI motility /pH were discontinued for the study and the WMC was ingested following a standardised nutrient bar meal. Data on gastric emptying time (GET), small bowel transit time (SBTT), colonic transit time (CTT) and whole gut transit time (WGTT) were calculated. Results PD patients with gut symptoms showed significantly slower transit in the stomach (GET 5.2 vs. 2.7 h, p = 0.0003), colon (CTT 57.8 vs. 27.4 h, p = 0.02) and overall gut (WGTT 67.2 vs. 34.7 h, p = 0.02) compared to asymptomatic patients. Small Bowel transit (mean SBTT 4.17 h) did not significantly differ. GET, SBTT, CTT and WGTT did not differ between asymptomatic PD and controls. There was a significant correlation between the Wexner constipation score and CTT in all patients (p 0.05). Conclusion This study demonstrates that symptomatic PD patients have markedly delayed transit times throughout the whole gut compared to asymptomatic PD patients and controls. The correlation between scores and transit times suggest that WMC is a less useful indicator of gastric emptying than small bowel and colonic transit. Disclosure of Interest None Declared.