Assessment of Upper Esophageal Sphincter Function on High-resolution Manometry

Abstract

Background Globus is commonly encountered in clinical practice, but high-resolution manometry (HRM) characteristics are incompletely characterized. We evaluated HRM metrics in globus subjects, compared with age-matched and sex-matched dysphagia subjects and healthy controls. Study Twenty-four subjects with globus (53.3±2.3 y, 58% female) were compared with 24 age-matched and sex-matched subjects with nonobstructive dysphagia (52.5±2.5 y, 58% female), and 21 healthy controls (27.6±0.6 y, 52% female). Sphincter and segment anatomy, and pressure volume metrics assessed skeletal (proximal contractile integral) and smooth muscle contraction (distal contractile integral). Parameters significantly different across groups on univariate analysis were subjected to multivariate logistic regression and receiver-operating characteristic analysis to identify HRM predictors of globus. Results Upper esophageal sphincter (UES) postswallow residual pressures were highest in globus (2.6±0.5 vs. 2.3±0.5mm Hg in dysphagia and 0.6±0.6mm Hg in controls, P=0.03); 66.7% had recordable UES residual pressure, in contrast to 9.5% of controls, and 37.5% of dysphagia patients (P=0.0002). Although different from controls, UES length and basal pressure, and segment 1 parameters did not differ from dysphagia controls. In a multivariate model, measurable UES residual pressure (odds ratio, 6.33; 95% confidence interval, 1.79–25.96) independently predicted globus. Receiver-operating characteristic analysis identified a threshold of 0.4mm Hg UES residual pressure in segregating globus (sensitivity 66.7%, specificity 71.5%, positive predictive value 55.2%, and negative predictive value 80.0%). Conclusion HRM with measurement of UES residual pressure allows objective assessment of patients with globus sensation, and has potential to complement current diagnostic strategies.

Oropharyngeal acid reflux and motility abnormalities of the proximal esophagus

“…Even though the PCI metric is not included in the Chicago Classification, it has been evaluated in a few published studies, including patients with extra-esophageal symptoms[18-20]. We found it was significantly lower in the group with pathological OP acid exposure.…”

“…The metrics analyzed included: sphincters lengths and resting pressures, lower esophageal sphincter (LES) integrated relaxation pressure (IRP-4s) and distal contractile integral (DCI), as previously defined[15-17]. We also calculated the proximal contractile integral (PCI, Figure 1), applying the same algorithm as for the DCI, to quantify contractile pressure exceeding 20 mmHg for the region spanning from the lower border of the UES to the transition zone (TZ)[18-20]. The individual swallow patterns were classified as peristaltic, premature (distal latency-DL < 4.5 s), hypercontractile (DCI > 8000 mmHg•s•cm), failed (DCI < 100 mmHg•s•cm), weak (DCI < 450 mmHg•s•cm), and fragmented contraction (defect in the 20-mmHg isobaric contour of the peristaltic contraction > 5 cm)[16].…”

Supragastric belch may be related to globus symptom – a prospective clinical study

“…Peng et al ., in their retrospective study, investigated UES basal and residual pressure between globus and dysphagia patients and normal controls, finding that mean UES basal pressure was normal in globus patients and normal controls, even though mean UES basal pressure was elevated in globus patients more often (16.7% vs 9.5%). Moreover, among globus patients, mean residual pressure was also within normal limits . When results in HRM were compared between globus and GERD patients and with normal controls, differences between these groups in UES basal pressure were statistically non‐significant .…”

Effect of citalopram on esophageal motility in healthy subjects—Implications for reflux episodes, dysphagia, and globus

“…The parameters studied and included for analysis were as follows: UES resting pressure before, during, and after swallowing protocol, UES pressure immediately after swallowing/UES re‐closure (UES postswallow mean and maximum pressure), as higher postswallow residual pressures have been associated with globus in a previous study, UES postprandial pressure, UES integrated relaxation pressure (IRP) 0.2 seconds, distal contractile integral (DCI), distal latency (DL), contractile front velocity (CFV), esophagogastric junction (EGJ) IRP4s, EGJ resting pressure before, during, and after swallowing protocol, EGJ resting pressure during first and second postprandial hour (all referenced to intragastric pressure (IGP)), postprandial IGP, number of TLESRs, and reflux episodes. Throughout the study, the sensations of fullness, nausea, belching, satiety, hunger, and heartburn were measured every 15 minutes using validated 100‐mm visual analogue scales (VAS).…”