Normal values of esophageal pressure responses to a rapid drink challenge test in healthy subjects: results of a multicenter study

Background Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral <450 mm Hg cm s) coexist with normal lower esophageal sphincter relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high‐resolution manometry (HRM). Ineffective esophageal motility is not consistently related to disease states or symptoms and may be seen in asymptomatic healthy individuals. Purpose A 1‐day symposium of esophageal experts reviewed existing literature on IEM, and this review represents the conclusions from the symposium. Severe IEM (>70% ineffective sequences) is associated with higher esophageal reflux burden, particularly while supine, but milder variants do not progress over time or consistently impact quality of life. Ineffective esophageal motility can be further characterized using provocative maneuvers during HRM, especially multiple rapid swallows, where augmentation of smooth muscle contraction defines contraction reserve. The presence of contraction reserve may predict better prognosis, lesser reflux burden and confidence in a standard fundoplication for surgical management of reflux. Other provocative maneuvers (solid swallows, standardized test meal, rapid drink challenge) are useful to characterize bolus transit in IEM. No effective pharmacotherapy exists, and current managements target symptoms and concurrent reflux. Novel testing modalities (baseline and mucosal impedance, functional lumen imaging probe) show promise in elucidating pathophysiology and stratifying IEM phenotypes. Specific prokinetic agents targeting esophageal smooth muscle need to be developed for precision management.

Section: Supplementary Investigationmentioning

confidence: 99%

Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium

Gyawali

Sifrim

Carlson

et al. 2019

“…As opposed to measuring contractile reserve like MRS, the best utility of RDC appears related to assessment of EGJ function. Normative values from two sizable cohorts were recently reported, and an IRP during RDC of ≥12 mm Hg (using a Sierra‐vintage HRM assembly) was proposed as a useful threshold to identify EGJ dysfunction associated with achalasia, and ≥8 mm Hg to identify “all cause” EGJ outflow obstruction . In addition, presence of pan‐esophageal pressurization during the RDC test may be indicative of achalasia and EGJ outflow obstruction .…”

Section: Rapid Drink Challenge Test (200 CC Drink)mentioning

confidence: 99%

“…In addition, presence of pan‐esophageal pressurization during the RDC test may be indicative of achalasia and EGJ outflow obstruction . Esophageal clearance of the 200 cc liquid (when impedance‐manometry is utilized) can also be assessed and while monitoring of the post‐swallow response for 30 seconds is often reported, monitoring for up to five minutes also allows measurement of an impedance bolus height, a measure similar to a barium column height on a timed‐barium esophagram …”

Section: Rapid Drink Challenge Test (200 CC Drink)mentioning

confidence: 99%

Esophageal provocation tests: Are they useful to improve diagnostic yield of high resolution manometry?

Carlson

Roman

2018

High resolution manometry (HRM) is the gold standard to diagnose esophageal motility disorders but has some limitations. The inclusion of provocative tests might enhance the diagnostic yield of HRM. These tests are easy to perform and to add to the regular manometry protocol. Multiple rapid swallows (MRS; 5 2-mL swallows) is useful to assess the contractile reserve and deglutitive inhibition. The optimal number of MRS to perform might be 3 as suggested by Mauro et al. in this issue of Neurogastroenterology & Motility. The absence of contractile reserve might be associated with gastro-esophageal reflux disease and with an increased risk of post fundoplication dysphagia. Single viscous and solid swallows might enhance the detection of esophageal motility disorders but are not significantly associated with symptom occurrence. Test meal has the advantage to represent a real-life scenario and is promising to depict significant motility findings responsible for esophageal symptoms. Post-prandial recording might also be of interest to diagnose rumination and belching disorders. The best indication of rapid drink challenge test (free drinking of 200 mL) is currently the diagnosis of esophago-gastric junction obstruction. Finally, abdominal compression might be an option to evaluate response of esophageal peristalsis in a context of outflow resistance as proposed by Brink et al. in this issue. These provocative maneuvers appear to provide a complementary role in the evaluation of esophageal motility but require prospective studies to determine the validity of the findings and whether they will lead to changes in clinical practice.

“…The rapid drink challenge test (RDC), which consist in asking the patient to drink 200 mL of water as rapid as possible, has been proposed as a valuable test to detect obstruction across the EGJ in patients with achalasia and other esophageal disorders . In recent studies, the normal range of pressure responses in healthy volunteers have been determined, and specific patterns of pressure responses have been described in patient populations with major and minor motility disorders . Three different patterns of pressure responses to the RDC have been described: a normal hypopressive pattern, that is characteristic of healthy controls and patients with minor motility disorders, a hyperpressive nonobstructive pattern, that is observed in patients with major motility disorders, and an obstructive pattern that is characteristic of patients with achalasia .…”

Section: Introductionmentioning

confidence: 99%

Rapid drink challenge test for the clinical evaluation of patients with Achalasia

Marín

Caballero

Guarner-Argente

et al. 2018