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Sustained esophageal contractions (SEC) have previously been described on high frequency esophageal ultrasound, high resolution manometry (HRM), and more recently on real time impedance planimetry with functional lumen imaging probe (FLIP). SEC may demonstrate a discoordination between circular and longitudinal esophageal smooth muscle contractions. The aim of this study was to determine the clinical characterization of SEC as detected on FLIP compared to HRM. Methods We performed a retrospective chart review of patients who underwent both FLIP and HRM at our Center for Esophageal Diseases between May 2017 and November 2019. FLIP endoscopic reports were reviewed for the presence of SECs which were defined as vigorous lumen closure ≥5 seconds at the LES or esophageal body as noted by the endoscopist during the real time FLIP examination of a sedated endoscopy. Primary variables recorded included EGJ distensibility index (EGJ-DI), diameter, and the presence of SECs at the 40 mL and 60 mL fill volumes. HRM diagnosis, clinical symptoms and outcomes were also reviewed. Results Of 165 patients who underwent HRM and FLIP imaging, 64 patients (mean age 53.7 years, 20 male) with SECs were included in the study. Among these patients, HRM demonstrated a wide variety of motility disorders (Figure 1). 40% of those with EGJOO, Type II or Type III achalasia, and all patients with jackhammer esophagus had SECs on FLIP imaging. Of 56 patients with normal motility or IEM, 22 had SECs, and 18 patients underwent an endoscopic intervention. Among those who had an intervention, 11 (61%) reported improvement in symptoms with improvement in Eckardt score from 4.9 to 3.9. Conclusion SECs are frequently present in hypercontractile esophageal disorders. Interestingly, 39% of patients with normal motility or IEM have SECs noted on FLIP, and 82% of these patients had an intervention performed based on FLIP findings with 61% reporting symptom improvement. Overall, 19% of patients with normal motility or IEM improved due to interventions performed based on SECs found on FLIP. Detection of SEC during FLIP imaging can guide treatment aimed at relaxation of esophageal muscles.

With high resolution manometry (HRM), achalasia is defined as an elevated integrated relaxation pressure (IRP) and the absence of normal esophageal peristalsis. Since achalasia symptoms are attributed in part to incomplete LES relaxation, IRP values might be expected to directly correlate with symptom severity. The aim of this study was to evaluate the relationship between IRP values and symptom severity assessed by the Eckardt score in patients with achalasia. Methods We searched the database of our Center for Esophageal Diseases for patients who had HRM showing achalasia (IRP > 15 mmHg and absent peristalsis) between May 2017 and August 2019. All patients with achalasia seen in our Center routinely complete the Eckardt score questionnaire evaluating the severity of achalasia symptoms in each of four categories (dysphagia, chest pain, regurgitation and weight loss). Pearson correlation coefficient was used to assess the relationship between median IRP and Eckardt score; an R2 value >0.5 was considered clinically meaningful. Results We identified 91 subjects with achalasia (mean age 62.9 ± 16.5 years; 39 men, 52 women; 27 Type 1, 28 Type 2, 36 Type 3). We found no clinically meaningful correlation between median IRP and the total Eckardt score (R2 = 0.043) (Figure 1). Furthermore, we found no clinically meaningful correlation between median IRP and any individual component of the Eckardt score (dysphagia R2 = 0.008, chest pain R2 = 0.001, regurgitation R2 = 0.035, weight loss R2 = 0.049). Finally, in subgroup analyses we found no clinically meaningful correlation between median IRP and Eckardt scores (total or any of its individual components) for any of the 3 achalasia subtypes. Conclusion We found no clinically meaningful correlation between IRP and total Eckardt score, or between IRP and any individual component of the Eckardt score for patients with achalasia of any type. This suggests that once the IRP value exceeds 15 mmHg, further elevations in IRP have little effect on symptoms, and that factors other than IRP such as esophageal body dysmotility and hypersensitivity might contribute to symptom perception in achalasia.

Volumetric laser endomicroscopy (VLE) has been shown to improve detection of early neoplasia in Barrett’s esophagus (BE). However, diagnostic performance using histopathology-correlated VLE regions of interest (ROIs) has not been adequately studied. We evaluated the diagnostic accuracy of VLE assessors for identification of early BE neoplasia in histopathology-correlated VLE ROIs. In total, 191 ROIs (120 nondysplastic and 71 neoplastic) from 50 BE patients were evaluated in a random order using a web-based module. All ROIs contained histopathology correlations enabled by VLE laser marking. Assessors were blinded to endoscopic BE images and histology. ROIs were first scored as nondysplastic or neoplastic. Level of confidence was assigned to the predicted diagnosis. Outcome measures were: (i) diagnostic performance of VLE assessors for identification of BE neoplasia in all VLE ROIs, defined as accuracy, sensitivity, and specificity; (ii) diagnostic performance of VLE assessors for only high level of confidence predictions; and (iii) interobserver agreement. Accuracy, sensitivity, and specificity for BE neoplasia identification were 79% (confidence interval [CI], 75–83), 75% (CI, 71–79), and 81% (CI, 76–86), respectively. When neoplasia was identified with a high level of confidence, accuracy, sensitivity, and specificity were 88%, 83%, and 90%, respectively. The overall strength of interobserver agreement was fair (k = 0.29). VLE assessors can identify BE neoplasia with reasonable diagnostic accuracy in histopathology-correlated VLE ROIs, and accuracy is enhanced when BE neoplasia is identified with high level of confidence. Future work should focus on renewed VLE image reviewing criteria and real-time automatic assessment of VLE scans.