Contraction Reserve With Ineffective Esophageal Motility on Esophageal High-Resolution Manometry is Associated With Lower Acid Exposure Times Compared With Absent Contraction Reserve

Abstract

INTRODUCTION: Ineffective esophageal motility (IEM) is a minor motor disorder with potential reflux implications. Contraction reserve, manifested as augmentation of esophageal body contraction after multiple rapid swallows (MRS), may affect esophageal acid exposure time (AET) in IEM. METHODS: Esophageal high-resolution manometry (HRM) and ambulatory reflux monitoring studies were reviewed over 2 years to identify patients with normal HRM, IEM (≥50% ineffective swallows), and absent contractility (100% failed swallows). Single swallows and MRS were analyzed using HRM software tools (distal contractile integral, DCI) to determine contraction reserve (mean MRS DCI to mean single swallow DCI ratio >1). Univariate analysis and multivariable regression analyses were performed to determine motor predictors of abnormal AET in the context of contraction reserve. RESULTS: Of 191 eligible patients, 57.1% had normal HRM, 37.2% had IEM, and 5.8% had absent contractility. Contraction reserve had no affect on AET in normal HRM. Nonsevere IEM (5–7 ineffective swallows) demonstrated significantly lower proportions with abnormal AET in the presence of contraction reserve (30.4%) compared with severe IEM (8–10 ineffective swallows) (75.0%, P = 0.03). Abnormal AET proportions in nonsevere IEM with contraction reserve (32.7%) resembled normal HRM (33.0%, P = 0.96), whereas that in severe IEM with (46.2%) or without contraction reserve (50.0%) resembled absent contractility (54.5%, P ≥ 0.6). Multivariable analysis demonstrated contraction reserve to be an independent predictor of lower upright AET in nonsevere (odds ratio 0.44, 95% confidence interval 0.23–0.88) but not severe IEM. DISCUSSION: Contraction reserve affects esophageal reflux burden in nonsevere IEM. Segregating IEM into severe and nonsevere cohorts has clinical value.

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

“… Supportive evidence for a diagnosis of IEM includes poor bolus transit on impedance or barium esophagram (Very Low GRADE, Conditional Recommendation) 73–75 Supportive evidence for a diagnosis of IEM includes lack of contraction reserve on MRS (Very Low GRADE, Conditional Recommendation) 25,76 …”

“…[73][74][75] • Supportive evidence for a diagnosis of IEM includes lack of contraction reserve on MRS (Very Low GRADE, Conditional Recommendation). 25,76 13 potensive EGJ. [77][78][79][80][81][82][83][84][85] • LES-CD separation should be scored as the distance between the center of the CD and LES signal during inspiration, unless obscured in which case the LES position should be scored at expiration (Strong Recommendation).…”

Postreflux swallow‐induced peristaltic wave index from pH‐impedance monitoring associates with esophageal body motility and esophageal acid burden

“…Esophageal smooth muscle can be challenged with provocative maneuvers such as MRS and can respond by augmenting contraction. The ability of the esophageal muscle to augment contraction, termed contraction reserve, correlates with abnormal reflux burden in prior studies 6 . In another study limited to endoscopy negative patients with heartburn, contraction reserve correlated with PSPWI in patients with normal HRM, abnormal AET (>4.2%), and elevated reflux episodes (>54 episodes/24 hours) 34 .…”

“…High‐resolution manometry (HRM) has proven benefit in the evaluation of esophageal transit symptoms 1,2 and has an emerging role in providing adjunctive evidence in gastroesophageal reflux disease (GERD) 3‐5 . Several HRM parameters and diagnoses including esophagogastric junction (EGJ) morphology, EGJ contractile integral (EGJ‐CI), severe ineffective esophageal motility (IEM), and absent contractility identify patients at risk of elevated acid exposure 4,6 . Intact esophageal peristalsis is a potential prerequisite for optimal reflux clearance.…”

“…Hypomotile disorders have an established relationship with elevated acid exposure, with a gradient of increasing reflux burden as proportions of ineffective and failed peristalsis increase 12,13 . Contraction reserve, the manometric demonstration of the capacity to augment esophageal smooth muscle contraction vigor with provocative testing such as multiple rapid swallows (MRS), may be associated with reduced reflux burden in individuals with hypomotile disorders 6 . However, relationships between PSPW, esophageal body contraction metrics, and reflux burden remain unclear.…”