Chaotic peak propagation in patients with Jackhammer esophagus

Abstract

Aims:The contractile activity of Jackhammer esophagus(JE) is heterogeneous and abnormalities in the balance of pre-and post-peak contractile activity has been reported. We observed that the progression of the peak contraction is disordered in JE patients, which reflect underlying abnormalities in the inhibitory and excitatory influence in esophageal contraction. In order to better define this abnormality, we developed novel time metrics to define trajectory of the pressure wave peak and assessed it in healthy controls and JE patients.Methods: 38 patients with JE (ages 43-70, 19 females) and 71 asymptomatic controls (ages 19-48; 33 females) were retrospectively evaluated. High resolution manometry was performed in all subjects with 10 supine liquid swallows. The first 5 intact supine swallows and supine swallow with the greatest DCI were analyzed using ManoView™ software and customized MATLAB program. The time distance, negative time distance sum and chaotic ratio were calculated. JE patients were subcategorized by the Brief Esophageal Dysphagia Questionnaire (BEDQ) with cutoff of 6.Results: Jackhammer patients had longer time distance, longer negative time distance, and higher chaotic ratio than controls(p < 0.001). The distribution of the number of negative time distances differed between JE patients with BEDQ>6 and BEDQ≤6. Conclusions:The trajectory of the pressure wave peak propagation commonly occurred in an unordered fashion in JE, but rarely in controls. Additionally, differences in pressure propagation trajectory was associated with higher symptom scores, thus trajectory of the pressure wave peak may be an important marker of abnormal esophageal motor function.

Esophageal motility disorders on high‐resolution manometry: Chicago classification version 4.0©

“…There are three general sub‐groups of hypercontractile esophagus: single‐peaked hypercontractile swallows, jackhammer with repetitive prolonged contractions (especially in the post‐peak phase), and hypercontractile swallows with a vigorous LES after‐contraction. The jackhammer subgroup of hypercontractile esophagus is typically associated with higher DCI values and worse symptom severity 66–68 . Overall the CCv4.0 working group recognizes the critical need for further research to better characterize physiologic phenotypes and clinical outcomes in hypercontractile esophagus.…”

The hypercontractile esophagus: Still a tough nut to crack

“…20 When esophageal contractions in patients with HE are divided into a pre-peak and a post-peak phase, regardless of the presence or absence of multiple peaks, postpeak hypercontractility is associated with higher overall contraction vigor and higher dysphagia scores. 21,22 Based on these observations, it seems wise to take esophageal pressure wave morphology into account in future studies on HE, to avoid lumping of repetitive and non-repetitive HE subtypes and not to use "jackhammer esophagus" as a pars pro toto term.…”

“…Recent observations suggest, however that, whereas the onset of the pressure waves may be peristaltic, subsequent peaks often propagate in a chaotic fashion, and that an increased "chaotic ratio" is associated with higher dysphagia symptom scores. 21,22 To accept a cause-effect relationship, a correlation between contractile vigor and presence or severity of dysphagia would help. For this reason, various studies have attempted to link higher contraction vigor to more frequent or more severe symptoms (both dysphagia and chest pain).…”

“…It has been reported that HE patients without the repetitive peak feature more often have a high IRP and impaired deglutitive EGJ relaxation than those with the feature 20 . When esophageal contractions in patients with HE are divided into a pre‐peak and a post‐peak phase, regardless of the presence or absence of multiple peaks, post‐peak hypercontractility is associated with higher overall contraction vigor and higher dysphagia scores 21,22 …”

“…At first glance, it is not easy to understand how the dysphagia associated with HE could be brought about by abnormally powerful but peristaltic esophageal contractions. Recent observations suggest, however that, whereas the onset of the pressure waves may be peristaltic, subsequent peaks often propagate in a chaotic fashion, and that an increased “chaotic ratio” is associated with higher dysphagia symptom scores 21,22 …”