Opioid-Induced Esophageal Dysfunction (OIED) in Patients on Chronic Opioids

Ratuapli, Shiva K.; Crowell, Michael D.; DiBaise, John K.; Vela, Marcelo F.; Ramirez, Francisco C.; Burdick, George E.; Lacy, Brian E.; Murray, Joseph A.

doi:10.1038/ajg.2015.154

Cited by 178 publications

(171 citation statements)

References 30 publications

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“…(18-20) While rapid-acting opiates and benzodiazepines may cause transient changes in esophageal motility parameters (with some inconsistencies, previous studies reported opiates generally increased EGJ pressures and benzodiazepines generally reduced or did not affect EGJ pressures), short-term opiate use is unlikely to alter the neural networks that are hypothesized to account for the association of esophageal motility disorders with chronic opiate use. (19, 21-25) Additionally, our analysis paradigm is based on control subjects also evaluated during endoscopy with conscious sedation and we did not observe differences in dosage or utilization of sedating agents across FLIP topography findings ( Table 2 ). Regardless of the use during sedation, FLIP topography motility classifications ultimately appeared to accurately characterize patients.…”

Section: Discussionmentioning

confidence: 81%

Evaluation of Esophageal Motility Utilizing the Functional Lumen Imaging Probe

Carlson

Kahrilas

Lin

et al. 2016

American Journal of Gastroenterology

211

269

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Background Esophagogastric junction (EGJ) distensibility and distension-mediated peristalsis can be assessed with the functional lumen imaging probe (FLIP) during a sedated upper endoscopy. We aimed to describe esophageal motility assessment using FLIP topography in patients presenting with dysphagia. Methods 145 patients (ages 18 – 85, 54% female) with dysphagia that completed upper endoscopy with a 16-cm FLIP assembly and high-resolution manometry (HRM) were included. HRM was analyzed according to the Chicago Classification of esophageal motility disorders; major esophageal motility disorders were considered ‘abnormal’. FLIP studies were analyzed using a customized program to calculate the EGJ-distensibility index (DI) and generate FLIP topography plots to identify esophageal contractility patterns. FLIP topography was considered ‘abnormal’ if EGJ-DI was < 2.8 mm2/mmHg or contractility pattern demonstrated absent contractility or repetitive, retrograde contractions. Results HRM was abnormal in 111 (77%) patients: 70 achalasia (19 type I, 39 type II, 12 type III), 38 EGJ outflow obstruction, and three jackhammer esophagus. FLIP topography was abnormal in 106 (95%) of these patients, including all 70 achalasia patients. HRM was ‘normal’ in 34 (23%) patients: five ineffective esophageal motility and 29 normal motility. 17 (50%) had abnormal FLIP topography including 13 (37%) with abnormal EGJ-DI. Conclusions FLIP topography provides a well-tolerated method for esophageal motility assessment (especially to identify achalasia) at the time of upper endoscopy. FLIP topography findings that are discordant with HRM may indicate otherwise undetected abnormalities of esophageal function, thus FLIP provides an alternative and complementary method to HRM for evaluation of non-obstructive dysphagia.

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Section: Discussionmentioning

confidence: 81%

Evaluation of Esophageal Motility Utilizing the Functional Lumen Imaging Probe

Carlson

Kahrilas

Lin

et al. 2016

American Journal of Gastroenterology

211

269

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“…EGJ Consequently, EGJOO always requires more intense clinical evaluation (for example, with endoscopic ultrasono graphy, FLIP and CT, among others) to clarify its aetiology. Potential aetio logies include incompletely expressed or early achalasia, oesophageal wall stiffness from an infiltrative disease or cancer, vascular obstruction, sliding or para-oesophageal hiatal hernia, abdominal obesity or the effects of opiates 44 . Similar findings are found also in patients with dysphagia after restrictive, antireflux and bariatric procedures [45][46][47] .…”

Section: Achalasia With Preserved Peristalsismentioning

confidence: 99%

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Kahrilas

Bredenoord

Fox

et al. 2017

Nat Rev Gastroenterol Hepatol

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High-resolution manometry (HRM), along with the analysis algorithms characterized in the Chicago Classification (CC) first proposed in 2008, have led to a major restructuring of the classification of oesophageal motility disorders. The inherently quantitative output of HRM devices fuelled enthusiastic expectation among motility experts that these advances would add a level of precision to the diagnosis of oesophageal motility disorders that was not previously possible. Nowhere was this advance more evident than in our concept of achalasia, now differentiated into subtypes as a direct result of HRM. Coincident with the assimilation of HRM into clinical practice was the development of a major therapeutic intervention for the management of oesophageal motility disorders, per-oral endoscopic myotomy (POEM). Not only does the POEM procedure provide a therapeutic option for myotomy with reduced morbidity relative to laparoscopic or open myotomy, but it also enables a calibrated intervention that is customized to patient-specific physiology. Together, these develop ments fostered an increasing emphasis on targeting therapy to specific aspects of oesophageal dysfunction, as measured by physiological testing, rather than discrete diagnoses. Again, nowhere is this evolution more evident than in our strategies for managing achalasia. This Consensus Statement examines the effect of HRM on our current understanding of oesophageal motility disorders with a focus on how this technology has affected the diagnosis, epidemiology and management of achalasia and achalasia-like syndromes. on behalf of the International Working Group for Disorders of Gastrointestinal Motility and FunctionAbstract | High-resolution manometry (HRM) and new analysis algorithms, summarized in the Chicago Classification, have led to a restructured classification of oesophageal motility disorders. This advance has led to increased detection of clinically relevant disorders, in particular achalasia. It has become apparent that the cardinal feature of achalasia -impaired lower oesophageal sphincter (LES) relaxation -can occur in several disease phenotypes: without peristalsis (type I), with pan-oesophageal pressurization (type II), with premature (spastic) distal oesophageal contractions (type III), or with preserved peristalsis (outlet obstruction). Furthermore, no manometric pattern is perfectly sensitive or specific for achalasia caused by a myenteric plexopathy, and there is no biomarker for this pathology. Consequently, physiological testing reveals other syndromes not meeting achalasia criteria that also benefit from therapies formerly reserved for achalasia. These findings have become particularly relevant with the development of a minimally invasive technique for performing a long oesophageal myotomy, the per-oral endoscopic myotomy (POEM). Optimal management is to render treatment in a phenotype-specific manner; that is, POEM calibrated to patient-specific physiology for spastic achalasia and the spastic disorders, and more conservative strategies...

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“…Alternatively, EGJ outflow obstruction may also be secondary to esophageal wall stiffness from an infiltrative disease or cancer, eosinophilic esophagitis, vascular obstruction, sliding or paraesophageal hiatal hernia, abdominal obesity, or the effects of opiates. 9,24 Consequently, EGJ outflow obstruction always requires more intense clinical evaluation to clarify its etiology (eg, endoscopic ultrasound, computed tomography, timed barium esophagram). Prior surgery should also be considered as similar manometric findings can be found after anti-reflux or bariatric surgery, sometimes making it very difficult to establish cause and effect.…”

Section: Expansion Of the Indications For Lower Esophageal Sphincter mentioning

confidence: 99%

Clinical Practice Update: The Use of Per-Oral Endoscopic Myotomy in Achalasia: Expert Review and Best Practice Advice From the AGA Institute

2017

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The purpose of this review is to describe a place for per-oral endoscopic myotomy (POEM) among the currently available robust treatments for achalasia. The recommendations outlined in this review are based on expert opinion and on relevant publications from PubMed and EMbase. The Clinical Practice Updates Committee of the American Gastroenterological Association proposes the following recommendations: 1) in determining the need for achalasia therapy, patient-specific parameters (Chicago Classification subtype, comorbidities, early vs late disease, primary or secondary causes) should be considered along with published efficacy data; 2) given the complexity of this procedure, POEM should be performed by experienced physicians in high-volume centers because an estimated 20–40 procedures are needed to achieve competence; 3) if the expertise is available, POEM should be considered as primary therapy for type III achalasia; 4) if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes; and 5) post-POEM patients should be considered high risk to develop reflux esophagitis and advised of the management considerations (potential indefinite proton pump inhibitor therapy and/or surveillance endoscopy) of this before undergoing the procedure.

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Opioid-Induced Esophageal Dysfunction (OIED) in Patients on Chronic Opioids

Abstract: Opioid use within 24 h of EPT is associated with more frequent EGJ outflow obstruction and spastic peristalsis compared with when opioid use is stopped for at least 24 h before the study.

Cited by 178 publications

References 30 publications

Evaluation of Esophageal Motility Utilizing the Functional Lumen Imaging Probe

Evaluation of Esophageal Motility Utilizing the Functional Lumen Imaging Probe

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Clinical Practice Update: The Use of Per-Oral Endoscopic Myotomy in Achalasia: Expert Review and Best Practice Advice From the AGA Institute

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