ABSTRACT
BACKGROUND: High-resolution esophageal manometry with impedance (HREMI) performed with supine patient positioning is used to evaluate patients for esophageal dysmotility. However, most patients experience symptoms related to esophageal dysmotility when eating or drinking upright. The aims of this study are to: (1) compare HREMI metrics in supine versus upright position; and (2) determine if upright position alters motility characterization of patients. METHODS: HREMI of twelve wet swallows in supine position and five wet swallows in upright position were performed on normal subjects (NS) and consecutive patients. Chicago Classification v3.0 (CC) diagnoses were evaluated in the supine position and a modified version of the Chicago Classification system was used in the upright position using normative upright values for DCI and IRP. RESULTS: DCI decreased in NS by 414 mmHg × cm × sec (p = 0.001) and patients by 613 mmHg × cm × sec (p < 0.001). IRP decreased in NS by 6.2 mmHg (p < 0.001) and patients by 4.6 mmHg (p < 0.001). The rate of successful bolus clearance decreased in the upright position in patients by 11% (p < 0.001), but no statistically significant differences were observed in NS. 82 of 200 patients (41%) had a change in CC diagnosis in the upright position. Bolus clearance in the upright position varied in patients depending on their diagnosis in the upright position. CONCLUSIONS: Upright swallows had lower LES, IRP, DCI and UES pressures in both normal subjects and patients with decreased bolus clearance in patients. Upright positioning can alter esophageal motility patterns and enhance diagnostic yield. Thus, upright swallows supplement supine swallows to help characterize esophageal dysmotility.
Subject(s)
Esophageal Motility Disorders , Electric Impedance , Esophageal Motility Disorders/diagnosis , Humans , Manometry , PostureABSTRACT
PURPOSE OF REVIEW: The purpose of this paper is to discuss current diagnostic and treatments of rumination. Rumination is often underdiagnosed or misdiagnosed in adults, especially when symptoms suggest regurgitation rather than vomiting accompanied by re-chewing and re-swallowing and should be included in the differential diagnosis. It is primarily diagnosed clinically by ROME-IV or DSM-5. RECENT FINDINGS: That rumination can be re-affirmed by characteristic patterns on objective testing such as high-resolution esophageal manometry and 24-h pH impedance testing. However, although gastroduodenal manometry and EMG are helpful, these tests are slowly losing interest given their technical nature of data gathering, time consumption, cost burden, and patient discomfort. SUMMARY: Rumination is primarily diagnosed clinically by ROME-IV or DSM-5 in addition to high-resolution esophageal manometry and 24-h pH impedance. Management is challenging and usually a combination of behavioral, pharmacological, and rarely surgical treatment. Recent data demonstrate that the combination of behavioral techniques such as diaphragmatic breathing exercises and/or with baclofen has promising results. Further research is necessary to further define objective criteria for diagnosis and other therapeutic modalities for treatment.
ABSTRACT
Horizontal pressure bands on high-resolution esophageal manometry with impedance (HREMI) tracings are often seen and thought to be due to cardiovascular structures compressing the esophagus. The aim of this study was to determine the prevalence and location of vascular pressure bands on HREMI studies and correlate these pressure bands to bolus clearance. HREMI studies in supine and upright positions from patients and normal volunteers were reviewed. Pressure bands were defined as bands of horizontal pressure greater than the 20 mmHg isobaric contour. Each swallow was reviewed with impedance to determine if bolus transit was impaired by the band. 38.6% of 251 patients and 36.4% of 11 normal controls had a pressure band present. There were a greater number of bands in supine versus upright position (patients: 130 vs. 25, P < 0.001 and controls: 6 vs. 1). Patients with pressure bands had similar demographics (age, gender, BMI) compared to those without. Average distal contractile integral of bands was greater in supine compared to upright (133 ± 201 vs. 60 ± 148 mmHg cm s, P < 0.05). Bands were commonly located clustered at 46 and 72% of esophageal length. Bolus transit was impaired by bands in 20.4% of supine and 14.0% of upright swallows. Vascular pressure bands can have a prominent appearance on HREMI studies, present in, being more prevalent and having greater pressure in the supine than the upright position. These vascular bands, when present, may impair esophageal transit.
