Multiple rapid swallows and rapid drink challenge in patients with esophagogastric junction outflow obstruction on high‐resolution manometry

Abstract

Background: Esophagogastric junction outflow obstruction (EGJOO) as defined by Chicago Classification of esophageal motility disorders (CCv3.0) encompasses a broad range of diagnoses, thus posing clinical challenges. Our aims were to evaluate multiple rapid swallow (MRS) and rapid drink challenge (RDC) during high-resolution manometry (HRM) to aid identifying clinically relevant EGJOO. Methods: Patients with a HRM diagnosis of EGJOO based on CCv3.0 that also completed MRS and RDC during HRM and barium esophagram were retrospectively identified. Radiographic EGJOO (RAD-EGJOO) was defined by either liquid barium retention or delayed passage of a barium tablet on barium esophagram. Thirty healthy asymptomatic controls that completed HRM were also included. MRS involved drinking 2 mL for 5 successive swallows. RDC involved rapid drinking of 200 mL liquid. Integrated relaxation pressure (IRP) and presence of panesophageal pressurization (PEP) during MRS and RDC were assessed. Key Results: One hundred one patients, mean (SD) age 56 (16) years, were included; 32% had RAD-EGJOO, 68% did not. RAD-EGJOO patients more frequently had elevated (>12 mmHg) upright IRP (100%), MRS-IRP (56%), RDC-IRP (53%), and PEP during RDC (66%) than both controls [17%; 0%; 7%; 3%] and patients without RAD-EGJOO [83%; 35%; 39%; 41%] Having IRP >12 mmHg during both MRS and RDC was twice as likely to be associated with RAD-EGJOO (19%) than those without RAD-EGJOO (9%) among patients with upright IRP >12 mmHg. Conclusions and Inferences: Adjunctive HRM maneuvers MRS and RDC appear to help identify clinically significant EGJOO. While future outcome studies are needed, comprehensive multimodal evaluation helps clarify relevance of EGJOO on HRM.

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

“… Multiple Rapid Swallows: An intact response to MRS is defined as absence of esophageal body contractility (DCI < 100 mmHg•s•cm) with complete deglutitive inhibition of the LES during the repetitive swallows, and presence of post‐MRS contraction augmentation (DCI post‐MRS greater than single swallow mean DCI; Table 2). 7,24–26 The post‐MRS contraction needs to be true peristaltic contractility and not artifact or pressurization. Rapid Drink Challenge: An intact response to RDC is defined as absence of esophageal body contractility (DCI < 100 mmHg•s•cm) with complete deglutitive inhibition of the LES during the RDC. When assessing response to RDC, IRP >12 mmHg (using Medtronic software) over the first 30 seconds of the RDC challenge and panesophageal pressurization >20 mmHg are criteria for outflow obstruction (Low GRADE, Conditional Recommendation) 9,26–29 .…”

“… 7,24–26 The post‐MRS contraction needs to be true peristaltic contractility and not artifact or pressurization. Rapid Drink Challenge: An intact response to RDC is defined as absence of esophageal body contractility (DCI < 100 mmHg•s•cm) with complete deglutitive inhibition of the LES during the RDC. When assessing response to RDC, IRP >12 mmHg (using Medtronic software) over the first 30 seconds of the RDC challenge and panesophageal pressurization >20 mmHg are criteria for outflow obstruction (Low GRADE, Conditional Recommendation) 9,26–29 . The presence of a normal contraction sequence following the RDC is a specific marker of normal contractility; however, this is not present in all healthy controls 9,27,28 …”

Chicago classification version 4.0© technical review: Update on standard high‐resolution manometry protocol for the assessment of esophageal motility

“…Data acquisition in two positions and inclusion of provocative tests can prolong data acquisition and variation in findings between tests can complicate the interpretation of HRM findings. The CCv4.0 working group recognizes that increased time required for data acquisition and analysis could be a barrier to implementation; however, the full protocol can be completed within 15 minutes and the inclusion of this information increases diagnostic sensitivity and specificity for clinically relevant diagnosis of esophageal motility disorders 24‐36 . “Inconclusive” findings on wet swallows can often be confirmed by these tests and, conversely, discordant findings in the secondary position and/or with provocation should prompt reconsideration of the diagnosis.…”

“…Augmentation is present if the DCI is in the normal range (ie, DCI >450 mm Hg.cm.s) and any of three post‐contractions have increased contractile vigor compared to the mean DCI from non ‐ failed single water swallows in the same position (ratio >1). The post‐MRS contraction needs to be true peristaltic contractility and not artifact or pressurization 32,35,44,47 …”

“…An intact response to RDC is defined as absence of esophageal body contractility (DCI <100 mm Hg•s•cm) with complete deglutitive inhibition of the LES during the RDC. When assessing response to RDC, IRP >12 mm Hg especially if accompanied by pan‐esophageal pressurization >20‐30 mm Hg (both with Medtronic software) are criteria for outflow obstruction 27,28,31,32,48 . RDC is especially recommended as a provocative test in patients with suspected EGJ outflow obstruction and achalasia in whom IRP does not reach diagnostic thresholds with single water swallows.…”