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Background: For many patients with lung disease the only proven intervention to improve survival and quality of life is lung transplantation (LTx). Esophageal dysmotility and gastroesophageal reflux (GER) are common in patients with respiratory disease, and often associate with worse prognosis following LTx. Which, if any patients, should be excluded from LTx based on esophageal concerns remains unclear. Our aim was to understand the effect of LTx on esophageal motility diagnosis and examine how this and the other physiological and mechanical factors relate to GER and clearance of boluses swallowed., Methods: We prospectively recruited 62 patients with restrictive (RLD) and obstructive (OLD) lung disease (aged 33-75 years; 42 men) who underwent high resolution impedance manometry and 24-h pH-impedance before and after LTx., Key Results: RLD patients with normal motility were more likely to remain normal (p = 0.02), or if having abnormal motility to change to normal (p = 0.07) post-LTx than OLD patients. Esophageal length (EL) was greater in OLD than RLD patients' pre-LTx (p < 0.001), reducing only in OLD patients' post-LTx (p = 0.02). Reduced EL post-LTx associated with greater contractile reserve (r = 0.735; p = 0.01) and increased likelihood of motility normalization (p = 0.10). Clearance of reflux improved (p = 0.01) and associated with increased mean nocturnal baseline impedance (p < 0.001) in RLD but not OLD. Peristaltic breaks and thoraco-abdominal pressure gradient impact both esophageal clearance of reflux and boluses swallowed (p < 0.05)., Conclusions and Inferences: RLD patients are more likely to show improvement in esophageal motility than OLD patients post-LTx. However, the effect on GER is more difficult to predict and requires other GI, anatomical and pulmonary factors to be taken into consideration., (© 2024 The Authors. Neurogastroenterology & Motility published by John Wiley & Sons Ltd.)

Menthol is thought to trigger gastroesophageal reflux disease (GERD) symptoms by influencing esophageal peristalsis and lower esophageal sphincter (LES) function. We evaluated the effect of esophageal menthol infusion on esophageal motility and the LES in healthy volunteers and in patients with GERD. High resolution manometry (HRM) catheter with attached thin tube for menthol infusion was placed transnasally. Protocol which included baseline recording, 16 water swallows (5 ml, 10 ml, and 15 ml) and the multiple rapid swallows was performed before and after esophageal infusion of menthol (3 mM, 20 min, 8 ml/min). We evaluated the effect of this infusion on the HRM parameters of esophageal peristalsis (distal contractile integral, distal latency, contractile front velocity) and the lower esophageal sphincter (LES) barrier function (integrated relaxation pressure and the inspiratory augmentation of the LES). Simultaneously we evaluated the quality and intensity of the symptoms during the menthol infusion. Esophageal infusion of menthol did not appreciably affect HRM measurements characterizing esophageal peristalsis and LES pressure in healthy subjects (N = 13) or GERD patients (N = 11). The magnitude of the distal contractile integral (5 ml) was changed neither in the healthy volunteers' group, (735 ± 127 vs. 814 ± 117 mmHg, p = 0.5), nor in the GERD patients (295 ± 78 vs. 338 ± 96 mmHg, p = 0.99). In healthy volunteers menthol did not change the inspiratory augmentation of the LES (8.67 ± 1.09 vs. 7.69 ± 0.96 mmHg, p = 0.15) and neither did for GERD patients (8.8 ± 1.18 vs. 8.22 ± 0.91 mmHg, p = 0.43). We observed no significant difference in any HRM parameter following menthol infusion, except for distal latency in 10 ml swallows. By contrast, menthol infusion induced significantly more intense discomfort in GERD patient than in healthy volunteers. Our results suggest no significant temporal effect of menthol on the esophageal motility or LES function, neither in healthy volunteers, nor in GERD. Arguably, other mechanisms are responsible for menthol-related heartburn., (© 2023. The Author(s).)

Introduction: Pre-operative evaluation of patients with gastroesophageal reflux disease (GERD) includes assessment of esophageal motility. High-resolution manometry (HRM) is the gold standard; endoscopic impedance planimetry (IP) with Endoflip 2.0 is increasingly utilized in esophageal disorders of motility. We hypothesized that normal IP motility would correlate with normal HRM motility and tested this in a prospective cohort study., Methods: Patients presenting for surgical evaluation of GERD between 9/2020 and 10/2021 were prospectively enrolled under an IRB-approved protocol. Patients with prior esophageal/gastric surgery, known motility disorders, or large paraesophageal hernias were excluded. All underwent HRM and IP, with normal motility defined by Chicago 3.0 classification for HRM and the presence of repetitive antegrade contractions for IP. Logistic regression and t test were used to analyze the data; p value < 0.05 was considered significant., Results: Of 63 patients enrolled, 48 completed both IP and HRM testing. The cohort was 50% male with a median age of 52.5 [42.0, 66.0] years, mostly ASA class 1-2 (75.1%, n = 36) and had an average BMI of 31.4 ± 6.3 kg/m 2 . Normal motility tracings were in 62.5% of IP and 75% of HRM tests. Using HRM as the gold standard, IP detected normal motility with a sensitivity of 65.8% and a specificity of 50% (positive predictive value 83.3%, negative predictive value 27.8%). Normal IP was not statistically significant in predicting normal HRM (OR 3.182, 95% CI 0.826-12.262, p = 0.0926). Tolerability of IP was significantly better than HRM with lower rates of discomfort (10.9% vs. 93.4%, p < 0.0001) and higher willingness to repeat testing (100% vs. 47.8%, p < 0.0001)., Conclusion: Esophageal motility testing with Endoflip 2.0 is well tolerated by patients. The low specificity (50%), poor negative predictive value (27.8%), and lack of statistically significant concordance between IP and HRM raises concern for the reliability of this test as a stand-alone replacement for HRM in the pre-operative evaluation for GERD., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Patients with obesity often report esophageal symptoms, with abnormal reflux and esophageal motility suggested as potential mechanisms. However, prior studies showed varying results, often limited by study design/size and esophageal function/symptom measures utilized. We aimed to examine the relationship between obesity and objective esophageal function testing and patient-reported outcomes, utilizing prospective symptom, manometric and reflux monitoring data with impedance., Methods: Adults referred for high-resolution impedance-manometry (HRiM) and multichannel intraluminal impedance-pH monitoring (MII-pH) to evaluate esophageal symptoms were enrolled. Validated symptom and health-related quality of life (HR-QOL) instruments were prospectively collected: GERDQ, reflux symptoms index (RSI), dominant symptom intensity (DSI, multiplied 5-point Likert scales for symptom frequency/severity), global symptom severity (GSS, 100-point visual analog scale), and Short Form-12 (SF-12) for HR-QOL. Esophageal function testing measures were compared across body mass index (BMI) categories and correlated with patient-reported outcomes., Key Results: Seven hundred and fifty four patients were included (Normal:281/Overweight:253/Class I obesity:137/Class II/III obesity:83). Reflux burden measures on MII-pH (acid exposure time, total reflux episodes, bolus exposure time), conclusive pathologic reflux (Lyon), and hiatal hernia were increased in higher obesity classes compared to normal BMI. Class II/III obesity was associated with more normal/hypercontractile swallows, less ineffective swallows, and better bolus transit on HRiM. BMI correlated positively with GERDQ/RSI/DSI/GSS, and negatively with physical component score (SF-12). Esophageal symptom severity and HR-QOL correlated strongly with MII-pH findings, but not HRiM measures., Conclusions/inferences: Obesity is associated with increased esophageal symptom burden and worse physical HR-QOL, which correlate with higher acid/bolus reflux burden but not altered esophageal motility/transit/contractile reserve., (© 2023 John Wiley & Sons Ltd.)

Background: Fundoplication is known to improve allograft outcomes in lung transplant recipients by reducing retrograde aspiration secondary to gastroesophageal reflux disease, a modifiable risk factor for chronic allograft dysfunction. Laparoscopic Nissen fundoplication has historically been the anti-reflux procedure of choice, but the procedure is associated with discernable rates of postoperative dysphagia and gas-bloat syndrome. Laparoscopic Toupet fundoplication, an alternate anti-reflux surgery with lower rates of foregut complications in the general population, is the procedure of choice on our institution's lung transplant protocol. In this work, we evaluated the efficacy and safety of laparoscopic Toupet fundoplication in our lung transplant recipients., Methods: A prospective case series of 44 lung transplant recipients who underwent laparoscopic Toupet fundoplication by a single surgeon between September 2018 and November 2020 was performed. Preoperative and postoperative results from 24-h pH, esophageal manometry, gastric emptying, and pulmonary function studies were collected alongside severity of gastroesophageal reflux disease and other gastrointestinal symptoms., Results: Median DeMeester score decreased from 25.9 to 5.4 after fundoplication (p < 0.0001), while percentage of time pH < 4 decreased from 7 to 1.1% (p < 0.0001). The severity of heartburn and regurgitation were also reduced (p < 0.0001 and p = 0.0029 respectively). Overall, pulmonary function, esophageal motility, gastric emptying, severity of bloating, and dysphagia were not significantly different post-fundoplication than pre-fundoplication. Patients with decreasing rates of FEV1 pre-fundoplication saw improvement in their rate of change of FEV1 post-fundoplication (p = 0.011). Median follow-up was 32.2 months post-fundoplication., Conclusions: Laparoscopic Toupet fundoplication provides objective pathologic acid reflux control and symptomatic gastroesophageal reflux improvement in lung transplant recipients while preserving lung function and foregut motility. Thus, laparoscopic Toupet fundoplication is a safe and effective antireflux surgery alternative in lung transplant recipients., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Gastroesophageal reflux disease (GERD) is a complex entity and one of the most frequents in general population. Association of GERD with obesity is clearly defined from an epidemiological point of view, where up to 40% of patients with overweight and obesity present reflux. Most of the risk factors associated to GERD are shared and especially frequent in patients with obesity. The pathophysiology that explain this correlation is complex and multifactorial, and includes both aspects related to physiology of motility, and anatomic changes. The malfunction of the lower esophageal sphincter, the greater transdiaphragmatic pressure gradient, pathological accumulation of fat and the high rate of hiatal hernia that comes with overweight will be the main factors that explain this correlation. Other factor like pathological eating habits or obesity related diseases have also an important role. In summary, it is the sum of the factors more than just one of them what would explain the pathophysiology of GERD in obese population., (Copyright © 2023 AEC. Published by Elsevier España, S.L.U. All rights reserved.)

Gastroesophageal reflux disease (GERD) is common in patients who have undergone lung transplantation and is associated with poorer outcomes, but guidelines are lacking to direct management strategies in this population. We assessed the diagnostic yield of impedance metrics compared to pH-metry alone for detecting GERD among lung transplant recipients and evaluated their association with clinical outcomes. We performed a retrospective cohort study of consecutive patients who underwent lung transplantation. Demographic data, acid exposure time (AET), number of reflux episodes, mean nocturnal baseline impedance (MNBI), post-reflux swallowing-induced peristaltic wave index (PSPWI), and clinical outcomes including mortality were collected. The relationship between GERD metrics and clinical outcomes was assessed using Wilcoxon signed-rank test and Fisher's exact test as appropriate. Of the 76 patients studied, 29 (38%) had GERD based on abnormal AET after lung transplantation. One (1.3%) patient had GERD based on elevated number of reflux episodes and abnormal distal MNBI detected GERD in 19 (26%) patients, resulting in 62% sensitivity and 94% specificity. Two (2.6%) patients had normal PSPWI. Patients with low distal MNBI had significantly decreased forced expiratory volume in 1 second (FEV1) at 3-year posttransplant compared to those without low distal MNBI (P = 0.03). Three-year survival was significantly worse among patients with elevated AET (66.7% vs. 89.1%, P = 0.03) but not with low distal MNBI (68.4% vs. 84.3%, P = 0.18). Abnormal AET is more sensitive for detecting GERD than other reflux metrics studied and is associated with survival, suggesting pH-metry alone may be sufficient to guide GERD management after lung transplant., (© The Author(s) 2022. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Supragastric belching (SGB) is a phenomenon where air is rapidly sucked from the pharynx into the esophagus and immediately expelled through abdominal straining. It is considered a behavior disorder and is increasingly recognized not only in patients with excessive belching, but also in those with reflux-like symptoms. Increased prevalence of esophageal hypomotility and increased acid exposure were previously reported in small cohorts of SGB patients. We aimed to clarify the impact of SGB on motility, reflux, and acid exposure in a large cohort of SGB patients., Methods: In a single-center database study, we searched for patients with pathological SGB. MII-pH and Manometry tracings were manually re-evaluated in all patients. Demographic, clinical, motility, reflux, and SGB-related data were gathered., Key Results: Three hundred and forty-eight patients were included. Heartburn, belching, and regurgitation were the most common symptoms. Ineffective esophageal motility (IEM) was found in 27% of patients. SGB related to 47% of all reflux and to 53.6% of acid reflux events, and accounted for 27.3% of acid exposure time (AET). In those with severe SGB, 62% of acid reflux events and 46% of AET were SGB-related., Conclusions & Inferences: Supragastric belching is common, associated with higher incidence of IEM and is responsible for almost a third of esophageal acid burden. The impact of SGB is proportional to its severity. Diagnosis of SGB should be sought in patients with excessive belching and in patients with refractory reflux symptoms. Recognizing SGB and treating patients with behavioral therapy may alleviate acid exposure and improve quality of life., (© 2022 The Authors. Neurogastroenterology & Motility published by John Wiley & Sons Ltd.)

Background: Quality indicators (QIs) are formal ways to track health care performance and outcomes, guide quality improvement, and identify gaps in care delivery. We developed twelve quality indicators for achalasia management which cover the domains of patient education, diagnosis, and treatment of achalasia., Aim: To determine adherence to established quality indicators for achalasia management., Methods: We performed a retrospective, multicenter evaluation of care patterns for adult patients greater than 18 years old with newly diagnosed achalasia from January 2018 to May 2020. A balanced random patient sample was obtained at four large academic medical centers. Independent electronic health record chart abstraction was performed using a standardized form to determine adherence to applicable QIs. Pooled and de-identified data were analyzed to identify gaps in care., Results: A total of 120 patients were included and the overall adherence to applicable quality indicators across all centers was 86%. The median follow-up for all patients from time of diagnosis to end of study was 511 days. Clinicians adhered to all applicable quality indicators in 49 patients (39%). The quality indicator domain with the poorest adherence was patient education (67%), with 50% of patients having had a documented discussion of the risks of gastroesophageal reflux disease following surgical or endoscopic myotomy., Conclusions: Gaps in the quality of achalasia care delivery were identified, the largest of which relates to patient education about treatment risks. These findings highlight a potential area for future quality improvement studies and form the basis for developing fully specified quality measures., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Esophageal distal baseline impedance (DBI) is an indicator of mucosal integrity; lower values suggest increased permeability. Aims were to characterize the (1) effect of DBI category (<900 Ω, 900-2000 Ω, and >2000 Ω) on sensory-motor characteristics of mid-esophageal provocation-induced motility reflexes, and (2) clinical outcomes among high-risk human infants evaluated for gastroesophageal reflux disease. Symptomatic infants (N = 49, 41 ± 3 weeks postmenstrual age) underwent pH-impedance testing to characterize acid reflux index (ARI) and DBI, and pharyngo-esophageal manometry to examine upper esophageal sphincter (UES), peristaltic, and lower esophageal sphincter (LES) functions. Sensory-motor response characteristics included response threshold (ml), occurrence (%), latency (s), duration (s), and magnitude (mmHg) upon mid-esophageal stimulations (0.1-2.0 ml of air, water, and apple juice). Motility and clinical outcomes were compared among DBI groups. In infants with DBI <900 Ω and 900-2000 Ω (vs. >2000 Ω): (a) Long-term feeding milestones did not differ (p > 0.05); (b) complete peristaltic propagation decreased in 900-2000 Ω (p < 0.05), polymorphic waveforms increased in <900 Ω and 900-2000 Ω (p < 0.05); (c) media effects were noted with liquids (vs. air) wherein UES and esophageal contractility were prolonged in <900 Ω and 900-2000 Ω (p < 0.05), and esophageal sensitivity heightened for <900 Ω with water and for 900-2000 Ω with air (both p < 0.05). ARI was not correlated with DBI in infants with chronic lung disease (r = 0.05, p = 0.82). We conclude that pharyngo-esophageal motility sensory-motor characteristics in infants are modified by DBI category. These preliminary findings pave-the-way for further physiological testing in convalescing high-risk infants to ascertain potential mechanisms of airway-digestive reflex interactions and symptom generation, which may lead to targeted therapies., (© 2022 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological Society.)

Background: The management of achalasia has improved due to diagnostic and therapeutic innovations. However, variability in care delivery remains and no established measures defining quality of care for this population exist. We aimed to use formal methodology to establish quality indicators for achalasia patients., Methods: Quality indicator concepts were identified from the literature, consensus guidelines and clinical experts. Using RAND/University of California, Los Angeles (UCLA) Appropriateness Method, experts in achalasia independently ranked proposed concepts in a two-round modified Delphi process based on 1) importance, 2) scientific acceptability, 3) usability, and 4) feasibility. Highly valid measures required strict agreement (≧ 80% of panelists) in the range of 7-9 for across all four categories., Key Results: There were 17 experts who rated 26 proposed quality indicator topics. In round one, 2 (8%) quality measures were rated valid. In round two, 19 measures were modified based on panel suggestions, and experts rated 10 (53%) of these measures as valid, resulting in a total of 12 quality indicators. Two measures pertained to patient education and five to diagnosis, including discussing treatment options with risk and benefits and using the most recent version of the Chicago Classification to define achalasia phenotypes, respectively. Other indicators pertained to treatment options, such as the use of botulinum toxin for those not considered surgical candidates and management of reflux following achalasia treatment., Conclusions & Inferences: Using a robust methodology, achalasia quality indicators were identified, which can form the basis for establishing quality gaps and generating fully specified quality measures., (© 2021 John Wiley & Sons Ltd.)

Background: The aim of the study is to determine if barium esophagram (BE) alone is sufficient to diagnose esophageal dysmotility when compared to the gold standard, high-resolution manometry (HRM)., Methods: This is a retrospective review of patients that underwent laparoscopic fundoplication by two surgeons at a single institution from 10/1/2015-6/29/2019. Patients with large paraesophageal hernias and patients without both BE and HRM were excluded., Results: Forty-six patients met the inclusion criteria. BE was found to be concordant with HRM for esophageal motility in only 21 patients (46%). Setting HRM as the gold standard, BE had a sensitivity of 14% (95% CI: 5%-35%), specificity of 72% (95% CI: 52%-86%), PPV of 30% (95% CI: 11%-60%), and NPV of 50% (95% CI: 35%-66%). The accuracy was 46%, while a McNemar test showed p = 0.028., Conclusion: Traditional BE should not be used in place of HRM for assessing pre-operative motility in patients undergoing anti-reflux surgery., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Gastroesophageal reflux disease (GERD) is a disorder due to the retrograde flow of refluxate into the esophagus. Although GERD is a common clinical diagnosis, its pathogenesis is quite complex. As a result of its multifactorial development, many patients continue to experience adverse symptoms due to GERD despite prolonged acid suppression with proton pump inhibitor therapy. The pathogenesis of GERD involves an interplay of chemical, mechanical, psychologic, and neurologic mechanisms, which contribute to symptom presentation, diagnosis, and treatment. As such, GERD should be approached as a disorder beyond acid. This review will investigate the major factors that contribute to the development of GERD, including factors related to the refluxate, esophageal defenses, and factors that promote pathologic reflux into the esophagus. In reviewing GERD pathogenesis, this paper will highlight therapeutic advances, with mention of future opportunities of study when approaching GERD., (© 2020 New York Academy of Sciences.)

Background/aim: Gastric dysmotility is one of pathophysiologies of gastroesophageal reflux disease (GERD). The aim of this study was to investigate the effects of transcutaneous electrical acustimulation (TEA) on gastric accommodation and gastric slow waves, and evaluate possible mechanisms in patients with GERD., Methods: Thirty patients were studied in two randomized sessions of sham-TEA and TEA with the measurements of esophageal high-resolution manometry (HRM), gastric accommodation assessed by a nutrient-drinking test, electrogastrogram (EGG), electrocardiogram (ECG), and postprandial dyspeptic symptoms., Results: Compared with sham-TEA, TEA improved nutrient drinking-induced fullness (42.0 ± 3.3 vs. 31.0 ± 3.5, P = 0.003) at 10 min after the drink, and belching right after the drink (22.0 ± 4.6 vs. 11.7 ± 3.1, P = 0.012) and at 10 min (16.0 ± 3.8 vs. 3.0 ± 1.5, P = 0.002) after the drink. TEA also improved gastric accommodation (954 ± 37 mL vs. 857 ± 47 mL, P = 0.001) and normalized maximal drink-induced impairment in gastric slow waves. Concurrently, TEA enhanced vagal activity assessed from spectral analysis of heart rate variability in the postprandial state (0.42 ± 0.03 vs. 0.49 ± 0.04, P = 0.039). The vagal activity was positively correlated with the percentage of normal slow waves (r = 0.528; P = 0.003) and negatively correlated with the regurgitation score (r = -0.408, P = 0.025)., Conclusions: Acute TEA increases gastric accommodation, improves gastric slow waves, and reduces postprandial fullness and belching, possibly mediated via the vagal mechanisms., (© 2019 International Neuromodulation Society.)

Lung transplantation is a high-risk, but lifesaving, procedure for patients with end-stage lung disease. Although 1-year survival is high, long-term survival is not nearly as high, due mainly to acute and chronic rejection. Bronchiolitis obliterans syndrome is the most common type of chronic rejection and often leads to poor outcomes. For this reason, esophageal testing in the lung transplant population has become a major issue, and this article discusses the evidence behind esophageal testing, the importance of esophageal dysmotility gastroesophageal reflux disease, both acidic and nonacidic reflux, and aspiration and the treatment of these findings., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Gastro-esophageal reflux disease (GERD) can present with typical or atypical or laryngo-pharyngeal reflux (LPR) symptoms. Pulmonary aspiration of gastric refluxate is one of the most serious variants of reflux disease as its complications are difficult to diagnose and treat. The aim of this study was to establish predictors of pulmonary aspiration and LPR symptoms., Methods: Records of 361 consecutive patient from a prospectively populated database were analyzed. Patients were categorized by symptom profile as predominantly LPR or GERD (98 GER and 263 LPR). Presenting symptom profile, pH studies, esophageal manometry and scintigraphy and the relationships were analyzed., Results: Severe esophageal dysmotility was significantly more common in the LPR group (p = 0.037). Severe esophageal dysmotility was strongly associated with isotope aspiration in all patients (p = 0.001). Pulmonary aspiration on scintigraphy was present in 24% of patients. Significant correlation was established between total proximal acid on 24-h pH monitoring and isotope aspiration in both groups (p < 0.01). Rising pharyngeal curves on scintigraphy were the strongest predictors of isotope aspiration (p < 0.01)., Conclusions: Severe esophageal dysmotility correlates with LPR symptoms and reflux aspiration in LPR and GERD. Abnormal proximal acid score on 24-h pH monitoring associated with pulmonary aspiration in reflux patients. Pharyngeal contamination on scintigraphy was the strongest predictor of pulmonary aspiration.

Background: Endoscopic variceal sequential ligation (EVSL) is currently endorsed in our hospital, as the preferred endoscopic treatment for prevention of variceal rebleeding and achieving adequate hemostasis. There is currently a lack of consensus surrounding EVSL-induced changes in esophageal motor function and abnormal reflux., Aims: To explore alterations in esophageal motor function and risk of abnormal gastroesophageal reflux in liver cirrhosis patients with esophageal varices, after EVSL., Methods: Twenty-one liver cirrhosis patients with esophageal varices were studied using manometry and 24-h pH monitoring 1 day prior to and 1 month following EVSL. The EVSL consisted of performing esophageal variceal ligation using a multi-band ligator, which was repeated every 4 weeks until the varices were eradicated., Results: The amplitude and duration of peristaltic contraction waves and the percentage of abnormal esophageal contraction waveforms were unaltered in both the proximal (P > 0.05) and the distal (P > 0.05) esophagus after EVSL. However, the lower esophageal sphincter pressure was decreased following EVSL (16.1 ± 7.9 mmHg vs 21.1 ± 6.3 mmHg (P < 0.05)). Various quantitative parameters including percentage of total monitoring time with pH < 4.0, total number of reflux episodes, number of reflux episodes > 5 min, and DeMeester scores were not increased in post-EVSL patients. Abnormal reflux monitored by 24-h pH monitoring occurred in ten (47.6%) pre-EVSL patients and 11 (52.4%) post-EVSL patients., Conclusions: Although EVSL affects esophageal motility by relatively decreasing LES pressure, it does not induce substantial motor abnormalities nor increase risk of abnormal gastroesophageal reflux disease in cirrhosis patients.

Background/aims: Transient lower esophageal sphincter relaxations (TLESRs) are the major cause of gastroesophageal reflux. Recently, an EP1 receptor antagonist, ONO-8539, showed the reduction of TLESRs in monkeys. However, its effect on TLESRs in humans remains unclear. This study investigated the effect of ONO-8539 on postprandial TLESRs in healthy male subjects., Methods: Twenty-seven subjects participated in this placebo-controlled, cross-over study. The subjects received either placebo or ONO-8539 (450 mg) after a standardized breakfast. A 30-min basal recording was performed 4 h after drug administration. Subsequently, TLESR recordings were performed after a high-fat test meal for 3 h. The examination was repeated at least 7 days from the first evaluation for washout., Results: Thirteen patients were ultimately analyzed. The basal lower esophageal sphincter pressure was not different between the 2 groups (16.3 and 18.0 mm Hg for placebo and ONO-8539, respectively; p = 0.88). ONO-8539 significantly reduced the number of TLESRs from 15.0 to 12.0 for 3 h (p < 0.05). The proportion of terminating events of TLESRs was significantly different between the 2 groups (p < 0.05). No events and swallowing terminated more TLESRs with ONO-8539 than with placebo., Conclusions: ONO-8539 suppressed TLESRs mildly. EP1 receptor may be involved with the mechanism of human TLESRs., (© 2019 S. Karger AG, Basel.)

Gastroesophageal reflux and esophageal dysmotility are common in patients with advanced lung disease and are associated with allograft dysfunction after lung transplantation. The effect of transplantation on reflux and esophageal motility is unclear. The aim of this study was to describe the changes in esophageal function occurring after lung transplantation. A retrospective cohort study was performed on lung transplant candidates evaluated at a tertiary care center between 2015 and 2016. A total of 76 patients who underwent lung transplantation had high-resolution manometry and ambulatory pH-metry before and after transplant. Demographic data, esophageal function testing results, and clinical outcomes such as pulmonary function testing were collected and analyzed using appropriate statistical tests and multivariable regression. Of the 76 patients, 59 (78%) received a bilateral transplant. There was a significant increase in esophageal contractility posttransplant, with an increase in median distal contractile integral from 1470 to 2549 mmHg cm s (P < 0.01). There were 19 patients with Jackhammer esophagus posttransplant, including 15 patients with normal motility pretransplant. Nine patients with ineffective or fragmented peristalsis pretransplant had normal manometry posttransplant. Abnormal pH-metry was observed in 35 (46%) patients pretransplant and 29 (38%) patients posttransplant (P = 0.33). Patients with gastroesophageal reflux disease posttransplant had less improvement in pulmonary function at one year, as measured by forced expiratory volume (P = 0.04). These results demonstrate that esophageal contractility increases significantly after lung transplantation, with an associated change in motility classification. In comparison, gastroesophageal reflux does not worsen, but is associated with worse pulmonary function, posttransplant., (© The Author(s) 2019. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: This study focuses on the impact of antireflux surgery in the outcome of tracheal stenosis., Methods: We performed a retrospective study including patients with benign tracheal stenosis who underwent esophageal manometry and dual-probe 24-hour ambulatory esophageal pH study. Patients with an abnormal pH study were managed with laparoscopic modified Nissen fundoplication or medically (omeprazole 80 mg/d, orally). Patients with normal pH study results were observed. After a 24-month follow-up, the outcome was considered satisfactory if tracheal stenosis could be managed by resection and there was no need for further dilatation or definitive decannulation. The management groups were compared using propensity score matching., Results: A total of 175 patients were included. Abnormal pH study results were found in 74 patients (42.3%), and 12.6% of patients had typical gastroesophageal reflux symptoms. Follow-up was completed in 124 patients (20 had fundoplication, 32 received omeprazole, and 72 were observed). After propensity score matching, the outcome of tracheal stenosis in the fundoplication group was similar to that of the observation group (odds ratio, 1; P = .99) and better than that of the omeprazole group (odds ratio, 5.31; P = .03). The observation (no gastroesophageal reflux) group had a better outcome of stenosis than those treated with omeprazole (odds ratio, 3.54; P = .02)., Conclusions: The outcome of the airway stenosis was superior after laparoscopic fundoplication compared with medical treatment with omeprazole and was similar to the outcome of patients without gastroesophageal reflux. A prospective randomized trial is warranted., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The pathophysiological mechanism(s) of gastroesophageal reflux disease (GERD)-related chronic cough (CC) is unclear. We aimed to determine the mechanism of reflux-induced cough by synchronous monitoring of reflux episodes, esophageal motility, and cough., Methods: Patients with GERD were prospectively enrolled and classified into GERD with CC (GERD-CC) and without CC (GERD) groups. Twenty-four-hour ambulatory pH-impedance-pressure monitoring was performed; the reflux patterns, esophageal motility during prolonged exposure to acid and characteristics of reflux episodes that induced coughing paroxysms were analyzed., Key Results: Thirty-one patients with GERD-CC and 47 with GERD were enrolled; all of whose monitoring results fulfilled the criteria for diagnosis of GERD. Patients with GERD-CC had higher reflux symptom scores, longer exposure to acid, higher DeMeester scores, and more frequent reflux episodes, proximal extent reflux detected by impedance, and higher percentage of strongly acidic reflux than patients in the GERD group (all P < .05). Of 63 reflux-cough episodes identified in the GERD-CC group, 74.6% of distal reflux and 67.0% of proximal reflux episodes were acidic. More patients had low pan-esophageal pressure in primary peristalsis (48.5% vs 11.8%, P = .000) and synchronous contraction in secondary peristalsis during prolonged exposure to acid in the GERD-CC than in the GERD group (63.9% vs 9.1%, P = .000)., Conclusions & Inferences: Proximal acidic reflux and distal reflux-reflex are jointly associated with reflux-induced cough in patients with GERD. Low pan-esophageal pressure in primary peristalsis and synchronous contraction in secondary peristalsis may play important roles in GERD-associated chronic cough., (© 2019 The Authors. Neurogastroenterology & Motility published by John Wiley & Sons Ltd.)

Objective: To investigate the characteristics of different phenotypes of refractory non-erosive gastroesophageal reflux disease (NERD), the types of esophageal motility and the related factors of symptoms. Methods: A retrospective analysis was made of the patients with refractory NERD of Beijing Tongren Hospital affiliated to Capital Medical University from September 2015 to August 2017. All patients underwent electronic gastroscopy, esophageal manometry and 24-hour dynamic esophageal pH impedance monitoring. They were divided into four phenotype groups according to the results. Results: A total of 231 patients were enrolled in the study. There were 111(48.1%)cases in phenotype 1 group, 9 (3.9%)cases in phenotype 2 group, 100 (43.3%)cases in phenotype 3 group and 11 (4.8%) cases in phenotype 4 group. Compared with the other three groups, the number of weak acid reflux [(86±55) vs (37±8), (70±52), (31±9) times] and the number of gas reflux [(86±76) vs (38±13), (58±57), (26±10)] in phenotype 1 group increased significantly (all P< 0.005). Dynamics disorders were common in refractory NERD patients (139/231, 60.2%). Mild esophageal dynamics disorder was the main type of dynamics disorder (118/139, 84.9%). There was no significant difference among the phenotype groups. Multivariate unconditional Logistic regression analysis showed that the risk factors for reflux-related symptoms were female ratio, Chicago power classification, gas reflux and weak acid reflux ( OR= 3.731, 2.452, 1.036 and 1.037, P< 0.05). Conclusions: The characteristics of gastroesophageal reflux and the types of motility disorders are different in different phenotype groups of refractory NERD patients. The risk factors of reflux-related symptoms are female ratio, Chicago motility classification, gas reflux and the frequency of weak acid reflux.

Background: High-resolution manometry (HRM), which is breakthrough testing equipment to evaluate esophageal motor function, was developed in Europe and United State and has garnered attention. Moreover, multichannel intraluminal impedance pH (MII-pH) testing has allowed us to grasp all liquid/gas reflux including not only acid but also non-acid reflux. We examined the impact of the presence of reflux esophagitis (RE) on esophageal motor function before and after laparoscopic fundoplication., Materials and Methods: The subjects included 100 patients (male: 63 patients, mean age: 54.1 ± 15.8) among 145 patients who underwent laparoscopic fundoplication for GERD associated diseases during a 4-year period from October 2012 to September 2016, excluding 6 patients who underwent further surgery, 32 patients on whom HRM was not performed, 3 patients who had technical errors during testing, and 4 patients for whom the status of RE was unknown. Regarding HRM, Mano Scan from Given Imaging Ltd. was used, and for the analysis, Mano View version 3.0 from the same company was used, after which data was calculated based on the Chicago Classification advocated by Pandolfino et al. Moreover, for the MII-pH testing, Sleuth manufactured by Sandhill Scientific. Inc. was used and automatic analysis was conducted by a computer. Postoperative assessments were conducted 3 months following surgery for all. Data was described in the median value and inter-quartile range, with a statistically significant difference defined as p < 0.05 by Chi square, Mann-Whitney, and Wilcoxon tests., Results: RE+ group (Los Angeles classification A:B:C:D = 7:9:16:12 patients) included 44 patients (44%), of older age compared to the RE- group (62 vs. 50 years, p = 0.012) and a higher Body Mass Index value (24.0 vs. 22.5, p = 0.045); however, no differences were observed in terms of gender and duration of symptoms. In the preoperative findings on MII-pH, the RE+ group demonstrated significantly longer acid reflux time (4.7 vs. 1.3%, p = 0.005), while in the HRM findings, the RE- group demonstrated a significantly longer abdominal esophagus (0 vs. 0.4 cm, p = 0.049) and maintained esophageal body motor function (DCI: 1054 vs. 1407 mmHg s cm, p = 0.021, Intact peristalsis ratio: 90 vs. 100%, p = 0.037). As to the comparison of the treatment effect before and after laparoscopic fundoplication (Toupet fundoplication for all), significant improvements were observed in both groups in various parameters regarding reflux including acid reflux time, total number of liquid reflux episodes and total number of reflux episodes. Moreover, for both groups, the total length of the lower esophageal sphincter (LES) (RE+ group: 2.7 vs. 3.2 cm, p = 0.001, RE- group: 3.0 vs. 3.4 cm, p = 0.003) and the total length of the abdominal esophagus (RE+ group: 0 vs. 1.6 cm, p < 0.001, RE- group: 0 vs. 1.8 cm, p = 0.001) were significantly extended following surgery; however, no change was observed in DCI before and after surgery., Conclusions: Regardless of the presence of RE, cardiac function and LES function were improved following laparoscopic Toupet fundoplication, but no changes were observed in esophageal body motor function.

Aim: To investigate the effect of dietary fiber on symptoms and esophageal function testing parameters in non-erosive gastroesophageal reflux disease (GERD) (NERD) patients., Methods: Thirty-six NERD patients with low (< 20 g/d) dietary fiber intake were enrolled in the study. They were examined with the use of symptom questionnaire (GERD-Q), high-resolution esophageal manometry, 24-h esophageal pH-impedance examinations, and food frequency questionnaire before and after 10 d of usual diet supplemented by psyllium 5.0 g TID. Complete data of 30 patients were available to the final analysis. The obtained results were analyzed with the use of non-parametric statistics (Wilcoxon matched pairs test)., Results: The number of patients experiencing heartburn was less (93.3% at baseline vs 40% at the end of the study, P < 0.001) and the GERD-Q score decreased (mean ± SD: 10.9 ± 1.7 vs 6.0 ± 2.3, P < 0.001) after the treatment period. Minimal resting lower esophageal sphincter (LES) pressure increased from 5.41 ± 10.1 to 11.3 ± 9.4 mmHg ( P = 0.023), but no change in residual LES pressure and mean resting pressure was found. Total number of gastroesophageal refluxes (GER) decreased from 67.9 ± 17.7 to 42.4 ± 13.5 ( P < 0.001) predominantly by acid and weak acid types of GERs. No significant change in mean esophageal pH and % of time pH < 4 was registered. Maximal reflux time decreased from 10.6 ± 12.0 min to 5.3 ± 3.7 min ( P < 0.05)., Conclusion: Fiber-enriched diet led to a significant increase of minimal lower esophageal sphincter resting pressure, a decrease of number of gastroesophageal refluxes, and a decrease of heartburn frequency per week in NERD., Competing Interests: Conflict-of-interest statement: Sergey Morozov, Vasily Isakov, Mariya Konovalova are the employee of Federal Research Center of Nutrition and Biotechnology, and have received research funding from Federal Agency for Scientific Organizations of Russia.

The pathogenesis of gastroesophageal reflux disease (GERD) is complex and involves changes in reflux exposure, epithelial resistance, and visceral sensitivity. The gastric refluxate is a noxious material that injures the esophagus and elicits symptoms. Esophageal exposure to gastric refluxate is the primary determinant of disease severity. This exposure arises via compromise of the anti-reflux barrier and reduced ability of the esophagus to clear and buffer the refluxate, leading to reflux disease. However, complications and symptoms also occur in the context of normal reflux burden, when there is either poor epithelial resistance or increased visceral sensitivity. Reflux therefore develops via alterations in the balance of aggressive and defensive forces., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: The management of paraesophageal hernia (PEH) is one of the most debated in surgery. Trends regarding indications, approach (open, laparoscopic, thoracoscopic), sac excision, mesh placement, and routine performance of fundoplication have changed over time. Today, most surgeons tend to perform a laparoscopic PEH repair that entails the excision of the sac, liberal use of a mesh to buttress the hiatus, and the addition of an anti-reflux procedure. Nevertheless, very little has been written on which type of fundoplication should be performed in these patients. Therefore, the goal of our study was to provide an evidence-based overview of which type of fundoplication should be performed during a PEH repair and the role of preoperative function tests in the decision-making METHODS: We searched the MEDLINE, Cochran, PubMed, Google Scholar, and Embase databases for papers published between 1996 and 2016 pertaining to the surgical treatment of PEH. We hand-searched the bibliographies of included studies and we excluded all reviews and case reports. We selected clinical studies and technical reports. We only considered papers stating rationales for the type of fundoplication performed., Results: Our search yielded 24 articles: 17 clinical studies and 7 technical reports. In five of the clinical studies, a fundoplication was added only to patients with reflux symptoms. In all clinical studies, the most performed procedure was a total fundoplication (Nissen or Nissen-Rossetti), whereas a partial fundoplication (Toupet more frequently than Dor) or no fundoplication was reserved to those with impaired esophageal motility. All seven technical reports recommended a tailored approach and suggested adding a partial fundoplication (mainly Toupet) when the manometric findings showed esophageal dismotility., Conclusion: The argument of whether or not a fundoplication should be added to a PEH repair in patients without evidence of reflux still persists. However, this review highlights that, when a fundoplication is performed, a tailored approach based on preoperative function tests is almost always preferred.

Introduction: The effect of the laparoscopic adjustable gastric band (LAGB) on esophageal acid exposure and reflux is poorly understood. Optimal technique and normative values for acid exposure have not been established in this group., Methods: High-resolution manometry (HRM) and 24-h ambulatory esophageal pH monitoring were performed in three groups: asymptomatic LAGB, symptomatic LAGB, and pre-operative reflux patients. This technique utilized intraluminal pressure signatures during HRM to guide accurate pH sensor placement., Results: The LAGB groups were well matched: age 48 vs 51 years (p = 0.249), weight loss 27.3 vs 26.7 kg (p = 0.911). The symptomatic group had a larger gastric pouch (5.2 vs 3.3 cm, p = 0.012), with higher esophageal acid exposure (10.8 vs 0.9%, p < 0.001). Two acidification patterns were observed: irritant and volume acidification, associated with substantial supine acidification. Symptomatic LAGB had altered esophageal motility, with poorer lower esophageal sphincter basal tone (8.0 vs 17.7 mmHg, p = 0.022) and impaired contractility of the lower esophageal segment (90 vs 40%, p = 0.009). Compared to pre-operative reflux patients, symptomatic LAGB patients demonstrated higher total and supine esophageal acid exposure (10.8 vs 7.0%, p = 0.010; 14.9 vs 5.1%, p < 0.001), less symptoms (2 vs 6, p = 0.001) and lower symptom index (0.7 vs 0.9, p = 0.010)., Conclusions: Ambulatory pH monitoring is an effective technique if the pH sensor is positioned appropriately using HRM. The correctly positioned LAGB appears associated with low esophageal acidification. In contrast, patients with symptoms or pouch dilatation can have markedly elevated esophageal acidification, particularly when supine. This is a different pattern compared to pre-operative patients and importantly can be disproportionate to symptoms.

The etiology and clinical impact of ineffective esophageal motility (IEM) remain poorly understood. Unless gastroesophageal acid reflux (GERD) is identified, symptomatic patients with IEM are challenging to treat. We sought to determine whether any clinical or functional characteristics could distinguish those patients with IEM and either normal or abnormal esophageal acid exposure.In this retrospective cohort study, we identified 46 consecutive patients presenting with heartburn, and other GER symptoms who underwent clinical, endoscopic, and functional evaluation that included high-resolution manometry (HRM) and ambulatory pH monitoring. IEM was defined using the Chicago Classification criteria (v.3) as ≥50% ineffective swallows (DCI ≤ 450 mmHg.s.cm). Esophageal acid exposure by ambulatory pH monitoring was considered abnormal when total time with esophageal pH < 4 exceeded 4.2%.Of the 46 IEM patients identified, 19 (mean age: 42 years, 37% female), had normal esophageal acid exposure and 27 patients, mean age 54 years, 33% female, evidence of pathologic acid reflux. There was a 12 years age difference between the groups, with those with normal acid exposure being significantly younger (P < 0.01); the mean body mass index (BMI) was 22.6 ± 0.6 in the normal group and 25.4 ± 0.7 in the abnormal group (P < 0.001); otherwise the groups were endoscopically and histologically similar. Symptoms were not discriminatory and heartburn and regurgitation were the most prevalent in both groups. HRM did not discriminate symptomatic patients with IEM and either normal or abnormal esophageal acid exposure. Proton pump inhibition (PPI) therapy was significantly more effective (74% vs. 10%) in patients with pathologic acid reflux (P < 0.001). As pH exposure becomes abnormal in the context of IEM, there is dominance for supine reflux.IEM appears to be an early, primary event, eventually associated with pathologic acid exposure, particularly supine. Higher BMI is also associated with abnormal esophageal acid exposure in such patients. GER symptoms are not discriminatory in patients with IEM with and without underlying pathologic acid reflux. Clinical response to PPI in such patients depends on the presence of esophageal pathologic acid exposure. Those with IEM and normal acid exposure remain symptomatic and mostly resistant to therapy., (© The Authors 2017. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Sleep disturbance is common in patients with gastroesophageal reflux disease (GERD). Secondary peristalsis is important for clearance of the refluxate from the esophagus. We aimed to test the hypothesis whether secondary peristalsis is impaired in GERD patients with sleep disturbance., Methods: Secondary peristalsis was stimulated with slow and rapid air injections into mid-esophagus in 8 age-matched health controls and 41 patients with GERD. Sleep disturbance was assessed by the Pittsburg Sleep Quality Index (PSQI). Objective sleep measures were assessed by ambulatory actigraphy., Results: The threshold volume for inducing secondary peristalsis during slow air injection was significantly higher in GERD patients with sleep disturbance than healthy controls (14.3 ± 1.2 vs. 8.9 ± 0.5 mL, p < .05). GERD patients with sleep disturbance had higher threshold volume of secondary peristalsis during rapid air injection than GERD patients without sleep disturbance (5.1 ± 0.4 vs. 3.9 ± 0.2 mL, p < .05) and healthy controls (5.1 ± 0.4 vs. 3.6 ± 0.2 mL, p < .05). There was a negative correlation between PSQI score and peristaltic frequency during rapid air injection (r = -.39, p = .01). Secondary peristaltic amplitude during rapid air injection was negatively correlated with wake after sleep onset (r = -.34, p = .04)., Conclusions: Sleep disturbance is associated with secondary peristaltic response to distension-induced esophageal stimulation in patients with GERD. Our study suggests that sleep disturbance per se may adversely influence the effectiveness of esophageal peristalsis and bolus clearance during sleep in patients with GERD.

Aim: To determine whether capsaicin infusion could influence heartburn perception and secondary peristalsis in patients with gastroesophageal reflux disease (GERD)., Methods: Secondary peristalsis was performed with slow and rapid mid-esophageal injections of air in 10 patients with GERD. In a first protocol, saline and capsaicin-containing red pepper sauce infusions were randomly performed, whereas 2 consecutive sessions of capsaicin-containing red pepper sauce infusions were performed in a second protocol. Tested solutions including 5 mL of red pepper sauce diluted with 15 mL of saline and 20 mL of 0.9% saline were infused into the mid-esophagus via the manometric catheter at a rate of 10 mL/min with a randomized and double-blind fashion. During each study protocol, perception of heartburn, threshold volumes and peristaltic parameters for secondary peristalsis were analyzed and compared between different stimuli., Results: Infusion of capsaicin significantly increased heartburn perception in patients with GERD ( P < 0.001), whereas repeated capsaicin infusion significantly reduced heartburn perception ( P = 0.003). Acute capsaicin infusion decreased threshold volume of secondary peristalsis ( P = 0.001) and increased its frequency ( P = 0.01) during rapid air injection. The prevalence of GERD patients with successive secondary peristalsis during slow air injection significantly increased after capsaicin infusion ( P = 0.001). Repeated capsaicin infusion increased threshold volume of secondary peristalsis ( P = 0.002) and reduced the frequency of secondary peristalsis ( P = 0.02) during rapid air injection., Conclusion: Acute esophageal exposure to capsaicin enhances heartburn sensation and promotes secondary peristalsis in gastroesophageal reflux disease, but repetitive capsaicin infusion reverses these effects., Competing Interests: Conflict-of-interest statement: There are no conflicts of interest to report.

Purpose: This study aimed to evaluate esophageal function before and after antireflux surgery (ARS) in neurologically impaired (NI) patients using 24 h multichannel intraluminal impedance (MII)-pH measurement., Methods: Seven NI patients (age, 0-33 years; median, 13 years) were assessed before and after ARS using 24 h MII-pH. We described reflux parameters such as pH reflux index, bolus exposure index, number of acidic and nonacidic reflux episodes, mean acid clearance time and median bolus clearance time, and esophageal motility parameters in dry swallows such as bolus presence time (BPT), total bolus transit time (TBTT), and total propagation velocity (TPV)., Results: The postoperative reflux parameters such as pH reflux index, acid clearance time, bolus exposure index, and the number of acidic reflux episodes significantly decreased (P < 0.05) compared with the preoperative ones. The esophageal motility parameters including all sites of BPTs, TBTT, and TPV did not change in the MII-pH measurement after ARS (P = non-significant)., Conclusion: ARS effectively reduced gastro-esophageal reflux (GER) in NI patients without the impairment of esophageal motility by MII-pH measurement. MII-pH was useful to detect the subtype of GER before and after ARS and appeared to be appropriate for evaluating esophageal motility.

Background: Using conventional manometry, gastro-esophageal reflux disease (GERD) was associated with a reduced lower esophageal sphincter (LES) pressure and impaired peristalsis. However, with a large overlap between GERD patients and controls, these findings are of limited clinical relevance. It is uncertain whether the more detailed information of high-resolution manometry (HRM) can discriminate GERD patients. Therefore, we aimed to determine to which extent HRM findings can predict GERD., Methods: HRM measurements in 69 patients with GERD and 40 healthy subjects were compared and the predictive value of HRM for the diagnosis of GERD was explored., Key Results: GERD patients had a significantly lower contraction amplitude (55 vs 64 mmHg; p = 0.045) and basal LES pressure (10 vs 13.2 mmHg; p = 0.034) than healthy controls. GERD patients more often had a hiatal hernia than healthy subjects (30% vs 7%; p = 0.005). Patients with reflux esophagitis had a lower DCI than patients without reflux esophagitis (558 vs 782 mmHg cm s; p = 0.045). No significant difference was seen in contractile front velocity, distal latency, number of peristaltic breaks, residual LES pressure and LES length. On multivariate logistic regression analysis, both esophagogastric junction type I (OR 4.971; 95% CI 1.33-18.59; p = 0.017) and mean wave amplitude (OR 0.95; 95% CI 0.90-0.98; p = 0.013) were found to be independent predictors of GERD. However, the sensitivity and specificity of these findings were low., Conclusions & Inferences: Hiatal hernia, low contraction amplitude and LES pressure are associated with GERD, but do not predict the disease with sufficient accuracy. Routine esophageal HRM can therefore not be used to distinguish GERD patients from healthy subjects., (© 2015 John Wiley & Sons Ltd.)

Background: Gastroesophageal reflux plays an important role in chronic cough (CC). Whether disturbed esophageal motility contributes to increased esophageal reflux exposure or interferes with swallowed bolus clearance is unclear. This study used high resolution esophageal manometry and impedance (HRIM) together with Chicago Classification, and 24-h impedance pH (MII/pH) to address these questions in patients with CC compared with heartburn (HB)., Methods: A retrospective review of 32 patients with CC (mean age 57 [95% CI: 52-62] years) and 32 patients with symptoms of HB (55 [52-62] years) referred for HRIM and MII/pH between September 2012 and September 2013 was undertaken., Key Results: Weak peristalsis with large breaks (WPLBs) was observed in 34% of CC patients compared with only 12% of HB patients (p = 0.027). Pathological acid exposure time (AET) was identified in 81% of CC patients with WPLBs compared with 29% without (p = 0.011). Increased AET was associated with prolonged clearance time of refluxed events (p = 0.006) rather than increased number of events. AET correlated with the percentage of peristaltic events with large breaks in CC (ρ = 0.467, p = 0.007). Similar data were obtained for total bolus (acid and non-acid) exposure time. Only one of the CC patients with WPLBs exhibited complete bolus transit (CBT) on swallowing compared with 81% without WPLBs (p < 0.001). Moreover, the percentage of peristaltic events associated with CBT negatively correlated with the percentage of peristaltic events with large breaks (r = -0.653, p < 0.001) in CC., Conclusions & Inferences: One-third of CC patients exhibit WPLBs, which directly impacts on clearance of refluxed events and bolus's swallowed. These observations may have important implications for esophageal-bronchial interaction in CC., (© 2015 John Wiley & Sons Ltd.)

Past studies have shown that catheter diameter is one of the device-dependent problems which influence the manometric results in the conventional water perfusion esophageal manometry. High-resolution solid-state manometry which abandons water perfusion is thought as an improved manometry method benefited from more pressure sensors, and it is gradually widely used in many present esophageal motility studies. There was no research to evaluate the influence of catheter diameter on the solid-state high-resolution manometry results. The aim of this study was to investigate whether solid-state high-resolution catheters of different diameter provide different data and results. Nine asymptomatic volunteers and 18 gastroesophageal reflux disease patients accepted high-resolution manometry examinations with two solid-state catheters of different outer diameter (4.2 mm and 2.7 mm). Every examination contained 5 minutes resting pressure, 10 water swallows and 10 bread swallows. Some important parameters of the esophageal sphincters and esophageal body peristalsis were analyzed. They included the locations and resting pressure of sphincters, the distal contractile integral, the 4-second integrated relaxation pressure etc. Then, these parameters and the diagnosis of each swallow based on them provided by the two different diameter catheters were compared. (i) The 4.2 mm thick catheter provided higher upper esophageal sphincter resting pressure than the 2.7 mm thick catheter (59.4 ± 21.1 mmHg vs. 49.7 ± 21.4 mmHg); (ii) the 2.7 mm thick catheter provided higher 4-second integrated relaxation pressure than the 4.2 mm thick catheter (10.9 ± 4.5 mmHg vs. 8.5 ± 3.8 mmHg) in water swallows; (iii) the mean distal contractile integral of the water and bread swallows in the large diameter catheter were higher than in the small diameter catheter (989.2 ± 650.0 mmHg/cm/s vs. 806.3 ± 563.7 mmHg/cm/s in water swallows, 1762.5 ± 1440.6 mmHg/cm/s vs. 1275.7 ± 982.0 mmHg/cm/s in bread swallows); (iv) on the lower esophageal sphincter resting pressure, most parameters in bread swallows provided by the two catheters were of no statistical significance; (v) the 2.7 mm thick catheter detected more hypotensive peristalsis swallows than the other catheter in water swallows; and (vi) the final diagnosis of about half of the subjects provided by the two catheters were different. The 2.7 mm thick solid-state high-resolution manometry catheter provides somewhat different data from the usually used 4.2 mm thick catheter. It is needed to set up different and independent series of normative value for the solid-state high-resolution manometry catheters of different outer diameter. The normative value and diagnostic criterion got from one catheter is not universal and acceptable for researches with catheter of different diameter., (© 2013 Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.)

Patients with symptoms suggestive of gastroesophageal reflux disease (GERD), such as chest pain, heartburn, regurgitation, and dysphagia, are typically treated initially with a course of proton pump inhibitors (PPIs). The evaluation of patients who have either not responded at all or partially and inadequately responded to such therapy requires a more detailed history and may involve an endoscopy and esophageal biopsies, followed by esophageal manometry, ambulatory esophageal pH monitoring, and gastric emptying scanning. To assess the merits of a multimodality 'structural' and 'functional' assessment of the esophagus in patients who have inadequately controlled GERD symptoms despite using empiric PPI, a retrospective cohort study of patients without any response or with poor symptomatic control to empiric PPI (>2 months duration) who were referred to an Esophageal Studies Unit was conducted. Patients were studied using symptom questionnaires, endoscopy (+ or - for erosive disease, or Barrett's metaplasia) and multilevel esophageal biopsies (eosinophilia, metaplasia), esophageal motility (aperistalsis, dysmotility), 24-hour ambulatory esophageal pH monitoring (+ if % total time pH < 4 > 5%), and gastric emptying scanning (+ if >10% retention at 4 hours and >70% at 2 hours). Over 3 years, 275 patients (147 men and 128 women) aged 16-89 years underwent complete multimodality testing. Forty percent (n= 109) had nonerosive reflux disease (esophagogastroduodenoscopy [EGD]-, biopsy-, pH+); 19.3% (n= 53) had erosive esophagitis (EGD+); 5.5% (n= 15) Barrett's esophagus (EGD+, metaplasia+); 5.5% (n= 15) eosinophilic esophagitis (biopsy+); 2.5% (n= 7) had achalasia and 5.8% (n= 16) other dysmotility (motility+, pH-); 16% (n= 44) had functional heartburn (EGD-, pH-), and 5.8% (n= 16) had gastroparesis (gastric scan+). Cumulative symptom scores for chest pain, heartburn, regurgitation, and dysphagia were similar among the groups (mean range 1.1-1.35 on a 0-3 scale). Multimodality evaluation changed the diagnosis of GERD in 34.5% of cases and led to or guided alternative therapies in 42%. Overlap diagnoses were frequent: 10/15 (67%) of patients with eosinophilic esophagitis, 12/16 (75%) of patients with gastroparesis, and 11/23 (48%) of patients with achalasia or dysmotility had concomitant pathologic acid reflux by pH studies. Patients with persistent GERD symptoms despite empiric PPI therapy benefit from multimodality evaluation that may change the diagnosis and guide therapy in more than one third of such cases. Because symptoms are not specific and overlap diagnoses are frequent and multifaceted, objective evidence-driven therapies should be considered in such patients., (© 2012 Copyright the Authors. Journal compilation © 2012, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.)

Gastroesophageal reflux disease (GERD), a prevalent clinical condition, is often attributed to aberrant esophageal motility, leading to gastric content reflux and associated symptoms or complications. The rising incidence of GERD presents an escalating healthcare challenge. Endoscopic and esophageal reflux monitoring can provide a basis for the diagnosis of patients with gastroesophageal reflux disease, but when the diagnostic basis is at an inconclusive value, some additional supportive evidence will be needed. Advanced technology is the key to improving patient diagnosis, accurate assessment, and the development of effective treatment strategies. High-resolution esophageal manometry (HREM) and endoscopic functional lumen imaging probe (EndoFLIP) represent the forefront of esophageal motility assessment. HREM, an evolution of traditional esophageal manometry, is considered the benchmark for identifying esophageal motility disorders. Its widespread application in esophageal dynamics research highlights its diagnostic significance. Concurrently, EndoFLIP's emerging clinical relevance is evident in diagnosing and guiding the treatment of coexisting esophageal motility issues. This review integrates contemporary research to delineate the contributions of HREM, EndoFLIP, and novel technologies in GERD. It examines their efficacy in facilitating an accurate diagnosis, differentiating similar gastrointestinal disorders, quantifying the extent of reflux, assessing the severity of the disease, forecasting patient responsiveness to proton pump inhibitor therapy, and guiding decisions for surgical interventions. The overarching aim is to deepen the understanding of GERD's underlying mechanisms and advance the formulation of holistic, efficacious treatment approaches. [ABSTRACT FROM AUTHOR]

Background/Aims: Ineffective esophageal motility (IEM) is common in patients with gastroesophageal reflux disease (GERD) and can be associated with poor esophageal contraction reserve on multiple rapid swallows. Alterations in the esophageal microbiome have been reported in GERD, but the relationship to presence or absence of contraction reserve in IEM patients has not been evaluated. We aim to investigate whether contraction reserve influences esophageal microbiome alterations in patients with GERD and IEM. Methods: We prospectively enrolled GERD patients with normal endoscopy and evaluated esophageal motility and contraction reserve with multiple rapid swallows during high-resolution manometry. The esophageal mucosa was biopsied for DNA extraction and 16S ribosomal RNA gene V3-V4 (Illumina)/full-length (Pacbio) amplicon sequencing analysis. Results: Among the 56 recruited patients, 20 had normal motility (NM), 19 had IEM with contraction reserve (IEM-R), and 17 had IEM without contraction reserve (IEM-NR). Esophageal microbiome analysis showed a significant decrease in microbial richness in patients with IEM-NR when compared to NM. The beta diversity revealed different microbiome profiles between patients with NM or IEM-R and IEM-NR (P = 0.037). Several esophageal bacterial taxa were characteristic in patients with IEM-NR, including reduced Prevotella spp. and Veillonella dispar, and enriched Fusobacterium nucleatum. In a microbiome-based random forest model for predicting IEM-NR, an area under the receiver operating characteristic curve of 0.81 was yielded. Conclusions: In symptomatic GERD patients with normal endoscopic findings, the esophageal microbiome differs based on contraction reserve among IEM. Absent contraction reserve appears to alter the physiology and microbiota of the esophagus. [ABSTRACT FROM AUTHOR]

Objectives: High‐resolution manometry (HRM) and esophagography are used for achalasia diagnosis; however, achalasia phenotypes combining esophageal motility and morphology are unknown. Moreover, predicting treatment outcomes of peroral endoscopic myotomy (POEM) in treatment‐naïve patients remains an unmet need. Methods: In this multicenter cohort study, we included 1824 treatment‐naïve patients diagnosed with achalasia. In total, 1778 patients underwent POEM. Clustering by machine learning was conducted to identify achalasia phenotypes using patients' demographic data, including age, sex, disease duration, body mass index, and HRM/esophagography findings. Machine learning models were developed to predict persistent symptoms (Eckardt score ≥3) and reflux esophagitis (RE) (Los Angeles grades A–D) after POEM. Results: Machine learning identified three achalasia phenotypes: phenotype 1, type I achalasia with a dilated esophagus (n = 676; 37.0%); phenotype 2, type II achalasia with a dilated esophagus (n = 203; 11.1%); and phenotype 3, late‐onset type I–III achalasia with a nondilated esophagus (n = 619, 33.9%). Types I and II achalasia in phenotypes 1 and 2 exhibited different clinical characteristics from those in phenotype 3, implying different pathophysiologies within the same HRM diagnosis. A predictive model for persistent symptoms exhibited an area under the curve of 0.70. Pre‐POEM Eckardt score ≥6 was the greatest contributing factor for persistent symptoms. The area under the curve for post‐POEM RE was 0.61. Conclusion: Achalasia phenotypes combining esophageal motility and morphology indicated multiple disease pathophysiologies. Machine learning helped develop an optimal risk stratification model for persistent symptoms with novel insights into treatment resistance factors. [ABSTRACT FROM AUTHOR]

Background: The post-reflux swallow-induced peristaltic wave (PSPW) brings salivary bicarbonate to neutralize residual distal esophageal mucosal acidification. Aims: To determine if reduced saliva production and esophageal body hypomotility would compromise PSPW-induced pH recovery in the distal esophagus. Methods: In this multicenter retrospective cross-sectional study, patients with confirmed Sjogren's syndrome and scleroderma/mixed connective tissue disease (MCTD) who underwent high resolution manometry (HRM) and ambulatory pH-impedance monitoring off antisecretory therapy were retrospectively identified. Patients without these disorders undergoing HRM and pH-impedance monitoring for GERD symptoms were identified from the same time-period. Acid exposure time, numbers of reflux episodes and PSPW, pH recovery with PSPW, and HRM metrics were extracted. Univariate comparisons and multivariable analysis were performed to determine predictors of pH recovery with PSPW. Results: Among Sjogren's syndrome (n = 34), scleroderma/MCTD (n = 14), and comparison patients with reflux symptoms (n = 96), the scleroderma/MCTD group had significantly higher AET, higher prevalence of hypomotility, lower detected reflux episodes, and very low numbers of PSPW (p ≤ 0.004 compared to other groups). There was no difference in pH-impedance metrics between Sjogren's syndrome, and comparison patients (p ≥ 0.481). Proportions with complete pH recovery with PSPW was lower in Sjogren's patients compared to comparison reflux patients (p = 0.009), predominantly in subsets with hypomotility (p < 0.001). On multivariable analysis, diagnosis of Sjogren's syndrome, scleroderma/MCTD or neither (p = 0.014) and esophageal hypomotility (p = 0.024) independently predicted lack of complete pH recovery with PSPW, while higher total reflux episodes trended (p = 0.051). Conclusions: Saliva production and motor function are both important in PSPW related pH recovery. [ABSTRACT FROM AUTHOR]

Achalasia is a rare esophageal disorder characterized by abnormal esophageal motility and swallowing difficulties. Pain and/or spasms often persist or recur despite effective relief of the obstruction. A survey by UK charity 'Achalasia Action' highlighted treatments for achalasia pain/spasms as a key research priority. In this patient-requested systematic review, we assessed the existing literature on pharmacological therapies for painful achalasia. A systematic review of the literature using Medline, Embase and Cochrane databases was performed to identify studies evaluating pharmacological therapies for achalasia. Methodological quality of included randomized controlled trials was assessed using the Cochrane Risk of Bias tool. In total, 70% (40/57) of survey respondents reported experiencing pain/spasms. A range of management strategies were reported. Thirteen studies were included in the review. Seven were randomized controlled trials. Most studies were >30 years old, had limited follow-up, and focussed on esophageal manometry as the key endpoint. Generally, studies found improvements in lower esophageal pressures with medications. Only one study evaluated pain/spasm specifically, precluding meta-analysis. Overall risk of bias was high. The achalasia patient survey identified that pain/spasms are common and difficult to treat. This patient-requested review identified a gap in the literature regarding pharmacological treatments for these symptoms. We provide an algorithm for investigating achalasia-related pain/spasms. Calcium channel blockers or nitrates may be helpful when esophageal obstruction and reflux have been excluded. We advocate for registry-based clinical trials to expand the evidence base for these patients. [ABSTRACT FROM AUTHOR]

Background/Aims: There is an increased incidence of gastroesophageal reflux disease (GERD) after lung transplantation (LT) that can be associated with graft dysfunction. It is unclear if the underlying esophageal motility changes in GERD are different following LT. This study aimed to use esophageal high-resolution manometry (HRM) to explore GERD mechanisms in LT recipients compared to matched controls. Methods: This was a retrospective study including patients with pathologic acid reflux who underwent HRM and pH testing at our healthcare facility July 2012 to October 2019. The study included 12 LT recipients and 36 controls. Controls were matched in a 1:3 ratio for age, gender, and acid exposure time (AET) Results: LT recipients had less hypotensive esophagogastric junction (EGJ) (mean EGJ-contractile integral 89.2 mmHg/cm in LT vs 33.9 mmHg/cm in controls, P < 0.001). AET correlated with distal contractile integral and total EGJ-contractile integral only in LT group (r = -0.79, P = 0.002 and r = -0.57, P = 0.051, respectively). Conclusions: Following LT, acid reflux is characterized by a less hypotensive EGJ compared to controls with similar AET. The strongest correlation with AET after LT was found to be esophageal peristaltic vigor. These results add to the understanding of reflux after LT and may help tailor an individualized treatment plan. [ABSTRACT FROM AUTHOR]

Backgrounds: Patients with systemic sclerosis (SSc) often have esophageal motility abnormalities and weak esophago-gastric junction (EGJ) barrier function, which causes proton pump inhibitor (PPI)-refractory reflux esophagitis (RE). The aims of this study were to clarify the current management of RE and prevalence and risk factors of medication-refractory RE in patients with SSc in Japan. Methods: A total of 188 consecutive patients with SSc who underwent both esophageal high-resolution manometry (HRM) and esophagogastroduodenoscopy (EGD) were reviewed. The presence of RE and grades of the gastroesophageal flap valve (GEFV) were assessed. Esophageal motility was assessed retrospectively according to the Chicago classification v3.0. When RE was seen on a standard dose of PPI or any dose of vonoprazan (VPZ), it was defined as medication-refractory RE. Results: Approximately 80% of patients received maintenance therapy with acid secretion inhibitors regardless of esophageal motility abnormalities. Approximately 50% of patients received maintenance therapy with PPI, and approximately 30% of patients received VPZ. Medication-refractory RE was observed in 30 patients (16.0%). In multivariable analyses, the number of EGD and absent contractility were significant risk factors for medication-refractory RE. Furthermore, combined absent contractility and GEFV grade III or IV had higher odds ratios than did absent contractility alone. Conclusions: Patients with persistent reflux symptoms and those with absent contractility and GEFV grade III or IV should receive maintenance therapy with strong acid inhibition to prevent medication-refractory RE. [ABSTRACT FROM AUTHOR]

Cerebellar ataxia with neuropathy and bilateral vestibular areflexia syndrome (CANVAS) is an hereditary autosomal recessive disease. Recent studies propose including chronic cough (CC) as a symptom of CANVAS. For 10 patients with CANVAS as genetically confirmed by biallelic expansion of the AAGG repeat motif (AAGGGexp) in intron 2 of replication factor C subunit 1 (RFC1), our aim was, as a multidisciplinary team, to describe clinical and functional characteristics and possible causes of CC following European Respiratory Society (ERS) recommendations, and to evaluate CC impact on quality of life (QoL) using self-administered questionnaires (Cough Severity Diary, Leicester Cough Questionnaire, Discrete Emotions Questionnaire, and EQ-5D-5L). In all 10 patients, the CC was a dry cough that developed several years prior to the neurological symptoms (mean 14.2 years); 7 patients had symptoms compatible with gastroesophageal reflux (GER), 5 with pathological GER diagnosed by 24-h esophageal pH testing, and 6 patients had impaired esophageal motility diagnosed by high-resolution esophageal manometry, most frequently ineffective peristalsis. Although further studies are required for confirmation, we conclude that CC may be a characteristic prodrome of CANVAS and may be related to GER and esophageal disorders. Furthermore, CC affects patients' QoL, especially in the psychosocial sphere. [ABSTRACT FROM AUTHOR]

Purpose: In gastro-esophageal reflux disease (GERD) requiring surgical treatment, concomitant ineffective esophageal motility (IEM) is a decisive factor in surgical planning, due to concern regarding dysphagia. Anti-reflux surgery with the RefluxStop device is a promising technique. We assessed initial feasibility and clinical outcomes of RefluxStop surgery in patients with GERD and IEM. Methods: Retrospective analysis of patients with GERD, hiatal hernia (HH), and IEM, who underwent surgery with RefluxStop at our institution and achieved 12-month follow-up. Technique feasibility was assessed, in addition to symptom resolution (GERD-HRQL questionnaire), adverse events, HH recurrence, dysphagia, and patient satisfaction. Placement of the device was confirmed by video fluoroscopy on postoperative day 1, and at 3 and 12 months. Results: Between June 2020 and November 2022, 20 patients with IEM underwent surgery with RefluxStop and completed 12-month follow-up. All patients reported typical symptoms of GERD, and 12 had preoperative dysphagia. The median HH length was 4.5 cm (IQR, 3.75–5). The median operating time was 59.5 min (IQR, 50.25–64) with no implant-related intra- or postoperative complications. No HH recurrence was observed. One patient reported persistent left-sided thoracic pain at 11 months post-surgery, which required diagnostic laparoscopy and adhesiolysis. Three patients reported severe postoperative dysphagia: balloon dilatation was performed towards resolution. The mean GERD-HRQL scores improved (from 40.7 at baseline to 4.8 at 3 months and 5.7 at 12 months (p <0.001)). Conclusion: RefluxStop surgery was feasible and offered effective treatment for this group of patients with GERD and IEM. All patients had complete resolution or significant improvement of GERD symptoms, and 90% of them were satisfied with their quality of life 1 year after surgery. [ABSTRACT FROM AUTHOR]

High-resolution manometry (HRM) facilitates the detailed evaluation of esophageal motility. In December 2020, Chicago classification (CC) version 4.0 introduced modifications to improve consistency and accuracy. We conducted this study to compare the differences in the interpretations of HRM examinations between CC 3.0 and 4.0. Consecutive HRM records at a Taiwan tertiary medical center, including wet swallows and MRS performed in both supine and sitting positions from October 2019 to May 2021, were retrospectively reviewed and analyzed using both CC versions 3.0 and 4.0. A total of 105 patients were enrolled, and 102 patients completed the exam, while three could not tolerate HRM sitting up. Refractory gastroesophageal reflux disease (GERD) symptoms (n = 65, 63.7%) and dysphagia (n = 37, 36.3%) were the main indications. A total of 18 patients (17.6%) were reclassified to new diagnoses using CC 4.0. Of the 11 patients initially diagnosed with absent contractility, 3 (27.3%) were reclassified as having Type 1 achalasia. Of the 18 patients initially diagnosed with IEM, 6 (33.3%) were reclassified as normal. The incidence of diagnosis changes was similar in both the dysphagia and refractory GERD symptoms groups (21.6% versus 15.3%, p = 0.43). The use of CC 4.0 led to changes in the diagnoses of esophageal motility disease, irrespective of examination indications. Early adoption improves the accuracy of diagnoses and affects patient management. [ABSTRACT FROM AUTHOR]

Background/Aims This study aims to evaluate the effects of acute codeine administration on primary and secondary esophageal peristalsis in patients with ineffective esophageal motility (IEM). Methods Eighteen IEM patients (8 women; mean age 37.8 years, range 23-64 years) were enrolled in the study. The patients underwent highresolution manometry exams, consisting of 10 single wet swallows, multiple rapid swallows, and ten 20 mL rapid air injections to trigger secondary peristalsis. All participants completed 2 separate sessions, including acute administration of codeine (60 mg) and placebo, in a randomized order. Results Codeine significantly increased the distal contractile integral (566 ± 81 mmHg·s·cm vs 247 ± 36 mmHg·s·cm, P = 0.001) and shortened distal latency (5.7 ± 0.2 seconds vs 6.5 ± 0.1 seconds, P < 0.001) for primary peristalsis compared with these parameters after placebo treatment. The mean total break length decreased significantly after codeine treatment compared with the length after placebo (P = 0.003). Codeine significantly increased esophagogastric junction-contractile integral (P = 0.028) but did not change the 4-second integrated relaxation pressure (P = 0.794). Codeine significantly decreased the frequency of weak (P = 0.039) and failed contractions (P = 0.009), resulting in increased frequency of normal primary peristalsis (P < 0.136). No significant differences in the ratio of impaired multiple rapid swallows inhibition and parameters of secondary peristalsis were detected. Conclusions In IEM patients, acute administration of codeine increases contraction vigor and reduces distal latency of primary esophageal peristalsis, but has no effect on secondary peristalsis. Future studies are required to further elucidate clinical relevance of these findings, especially in the setting of gastroesophageal reflux disease with IEM. [ABSTRACT FROM AUTHOR]

Background/Aims It has been suggested that STW5 (Iberogast) reduces heartburn symptoms in patients with functional dyspepsia, but underlying mechanisms of action are unclear. The aim of this study is to investigate whether STW5 affects esophageal sensitivity or esophageal motility, thereby reducing occurrence and perception of reflux events. Methods We performed a double-blind, randomized, placebo-controlled, crossover trial in patients with functional dyspepsia (Rome IV) and reflux symptoms. After 4 weeks of treatment with either placebo or STW5, patients were studied with an esophageal acid perfusion test and ambulatory 24-hour pH-impedance monitoring. Results A total of 18 patients (7 men, median age 54, range [19-76]), were included in the study. Although we found no statistical difference in our primary outcome the total Reflux Disease Questionnaire score 2.33 (0.25-4.33) vs 2.67 (1.17-4.00), P = 0.347, "gastroesophageal reflux disease" and "regurgitation" subscale scores were lower after STW5 treatment compared to placebo (P = 0.049 and P = 0.007). There was no statistical difference in number of reflux events, acid exposure time and acid sensitivity scores between STW5 and placebo. In a subgroup analysis of patients with pH-metry confirmed gastroesophageal reflux disease, treatment with STW5 significantly reduced the total number of acidic reflux events (P = 0.028). Moreover, in patients with reflux esophagitis, the median lag time to acid perception increased after STW5 treatment (P = 0.042). Conclusions We found some indications pointing towards a beneficial effect of STW5 on reflux symptoms in dyspeptic patients, with reduction of esophageal hypersensitivity as a potential underlying mechanism. Our findings will have to be confirmed in larger studies. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Gastroesophageal reflux disease (GERD) severity increases with esophageal body hypomotility, but the impact of Chicago Classification (CC) v4.0 criteria on GERD diagnosis is incompletely understood. METHODS: In patients with GERD evaluated with high-resolution manometry and pH-impedance monitoring, CCv3.0 and CCv4.0 diagnoses were compared. RESULTS: In 247 patients, hypomotility diagnosis decreased from 45.3% (CCv3.0) to 30.0% (CCv4.0, P< 0.001). In contrast, within patients with ineffective esophageal motility, proportions with pathological acid exposure increased from 38% (CCv3.0) to 88% (CCv4.0); baseline impedance and esophageal clearance demonstrated similar findings (P< 0.05 for each comparison). DISCUSSION: CCv4.0 hypomotility criteria are more specific in supporting GERD evidence compared with CCv3.0. [ABSTRACT FROM AUTHOR]

Background: Advances in high-resolution esophageal manometry (HREM) have overturned the clinical assessment of esophageal motility disorders. It has been widely incorporated into clinical practice as it is a delicate diagnostic tool for assessing esophageal motility patterns. Objective: To assess the diagnostic ability of HRM in categorization of esophageal motility disorder using the Chicago Classification v3.0 Patients and Methods: a retrospective descriptive study done on 100 adult patients who underwent esophageal manometry test in the Endoscopy unit of Gastroenterology and Hepatology center at Azadi Teaching Hospital in Duhok city. The study was conducted from January 2021 to March 2022 by reviewing the high-resolution esophageal manometry of these patients using the Chicago classification v3.0. The recorded esophageal symptoms were correlated with the findings obtained during HREM test. Results: The mean age of the participants was 44.8 years with a standard deviation of 16 year. Females were on average older than males with a mean age of 47.8 years compared to 41.2 year for males. More than half of the patients (53%) had dysphagia as the main symptom that HRM done for. Globus sensation was the second one (14%) followed by Gastroesophageal reflux disease (GERD) (13%). The yield of HRM found to be abnormal (77%) as esophageal motility disorders. Those patients with dysphagia had achalasia II as the highest frequency (28.3%), while no even one patient of those with GERD, globus sensation or nausea and vomiting had achalasia detected by HRM. The most frequent result of GERD patients was esophagogastric junction outflow obstruction (38.5%). More than half (57.1%) of patients with globus sensation had a normal HRM test. Distal esophageal spasm was found to be the most frequent finding among patient with non-cardiac chest pain. Conclusion: There is an apparent diagnostic value of HRM in categorization of esophageal dysmotility when applying the Chicago Classification v3.0 in those patients with suggestive symptoms of motility disorders. [ABSTRACT FROM AUTHOR]

Background: The esophagogastric junction (EGJ) is classified into 3 anatomical subtypes according to lower esophageal sphincter-crural diaphragm (LES-CD) separation. We aimed to assess their relationship to esophageal motility, reflux characteristics, and symptom perception. Methods: We analyzed data from 1740 consecutive patients with typical reflux symptoms, who underwent high resolution manometry and a 24-h pH-impedance study during a 13-year period. A diagnosis of gastroesophageal reflux disease (GERD) was made if acid exposure time (AET) was >6%. EGJ types were classified as 1, 2, or 3, if LES-CD separation was up to 1 cm, 1-3 cm, or =3 cm, respectively. Results: EGJ type distribution was 72.2%, 22.1% and 5.7%, for types 1, 2 and 3, respectively. GERD was diagnosed in 31.2% and was more common among patients with EGJ type 2/3 vs. 1 (P<0.001). Length of LES-CD separation significantly correlated with AET and number of reflux episodes. Patients with type 2 or 3 EGJ more often showed ineffective or absent peristalsis compared with type 1 (P=0.008 and P<0.001 respectively). In the multivariate analysis, EGJ type 2/3 correlated with AET (P=0.001) and reflux episodes (P=0.041) but not with positive symptomatic markers or with ineffective/absent peristalsis. Conclusions: Our study confirms that EGJ anatomical morphology is a strong risk factor for GERD and correlates with both AET and the number of reflux events, though the length of separation is more important than the type. The multivariate analysis revealed that EGJ type 2 or 3 was not correlated with symptom perception or esophageal hypomotility. [ABSTRACT FROM AUTHOR]