Manometric Subtypes of Ineffective Esophageal Motility

作者：Hiestand Mirjam; Jalil Ala' Abdel^*; Castell Donald O

来源：Clinical and Translational Gastroenterology, 2017, 8(3): e78.

DOI：10.1038/ctg.2017.4

OBJECTIVES: Ineffective esophageal motility (IEM) is characterized by well-defined manometric criteria. However, much variation exists within the diagnosis: Some patients exhibit exactly the required five weak swallows to make the diagnosis. Others show consistently ineffective swallows with total absence of any normal swallow. " We hypothesize" there are two different manometric subtypes of IEM; IEM Alternans (IEM-A) and IEM Persistens (IEM-P).
METHODS: A total of 231 IEM patients were identified by high-resolution manometry (HRM). IEM defined by distal contractile integral (DCI) o450 mm Hg/s/cm in >= 50% of test swallows. Abnormal reflux study was defined by excess total number of reflux episodes, abnormal esophageal acid exposure, or positive symptom association.
RESULTS: A total of 195 (84%) patients had IEM-A and 36 (16%) had IEM-P. A striking gender difference with 34% of IEM-A being males compared to 53% of IEM-P. (P= 0.03). Mean age of IEM-P (59.6 years+/ -13.1) was greater than IEM-A (55.5 years+/-13.6) (P= 0.04). Mean lower esophageal sphincter (LES) resting pressure was significantly lower in IEM-P (20.8 mm Hg+/-1.4) than IEM-A (29 mm Hg+/-1.2) (P= 0.002). There was no difference in LES-integrated relaxation pressure (IRP), bolus transit, or manometric presence of hiatal hernia between the two groups. Out of 146, 89 (61%) patients had abnormal reflux study. Esophageal acid exposure in upright position was significantly higher in IEM-P than IEM-A (3.5 vs. 1.7%, P= 0.04). Poor gastric acid control on proton pump inhibitor (PPI) was more prevalent among IEM-P patients (58%) than IEM-A (27%) (P= 0.007). In subgroup analysis of 41 IEM patients with dysphagia, DCI for liquid swallows was significantly lower in IEM-P (111+/-142 mm Hg/ s/ cm) compared to IEM-A (421+/-502 mm Hg/s/cm) (P= 0.04), lower mean LES resting pressure in IEM-P (16.6+/-9 mm Hg) than IEM-A (31.7+/-18 mm Hg) (P= 0.01).
CONCLUSIONS: There are two distinct manometric IEM subtypes; IEM-P with an older male predominance, more advanced reflux disease, weaker LES, and worse response to PPI; likely a more advanced manifestation than IEM-A. However, the question if there are different etiologies underlying the two subtypes remains to be answered.

• 出版日期2017-3