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sTu1988

Distal Esophageal Spasm According to the Chicago Classification: Is TimingEverything?Heiko De Schepper, Fraukje A. Ponds, Jac. Oors, André J. Smout, Albert J. Bredenoord

Introduction: According to the Chicago classification of esophageal motility disorders, distalesophageal spasm (DES) is defined as a normal mean integral relaxation pressure (IRP) incombination with premature esophageal contractions (distal latency (DL) < 4.5 s for ≥20%of swallows). However, a subset of patients with symptoms similar to DES have simultaneouscontractions on manometry (contractile front velocity (CFV) > 9.0 cm/s) but with a normalDL. In the Chicago classification this poorly characterized abnormality is labelled "rapidcontractions with normal latency" (RCNL). Aim: To investigate the differences betweenpatients with DES and patients with RCNL. Methods: We retrospectively evaluated theclinical characteristics and high-resolution manometric recordings of patients with a normalIRP and simultaneous esophageal contractions with and without a short DL. The results ofthe barium esophagogram were also taken into account (absence or presence of tertiarycontractions). Results: Since February 2012, 19 patients were identified. Of these, 8 fulfilledthe Chicago criteria for DES (DES), including a short DL. The remaining 11 patients showedsimultaneous contractions in the distal esophagus but with DL >4.5 s (RCNL). DES patientswere younger than RCNL patients (59 ± 4 versus 72 ± 3 years, P <0.05). There was nodifference in gender distribution between DES and RCNL. Symptoms of dysphagia andretrosternal pain occurred similarly in both groups. Weight loss and tertiary contractionson barium esophagogram tended to be more frequent in DES patients, although this wasnot statistically significant. There was no difference between the groups in the distal contractileintegral (DCI, 2006 ± 466 mmHg.cm.s in RCNL versus 2549 ± 955 mmHg.cm.s in DES),nor in the CFV (15.6 ± 3.5 cm/s in RCNL versus 18.5 ± 3.7 cm/s in DES) . Lower esophagealsphincter resting pressure was not different in DES versus RCNL. However, the IRP wassignificantly higher in DES compared to RCNL (11.7 ± 0.7 mmHg vs 7.6 ± 1.2 mmHg, P<0.05), albeit still within the normal range. Conclusion: Patients with DES (short DL) andpatients with RCNL (normal DL) have similar symptom profiles. DES patients are older andtend to show weight loss and an abnormal barium esophagogram more often than RCNLpatients. These data suggest that RCNL represents a subgroup of patients within the spasticcontraction spectrum, with less severe manifestations in an earlier phase of the diseaseprocess compared to DES with premature contractions.

Tu1989

Impact of Spatial Resolution on Results of Esophageal High-ResolutionManometryHeiko De Schepper, Boudewijn F. Kessing, Pim W. Weijenborg, Jac. Oors, André J.Smout, Albert J. Bredenoord

Introduction: The Chicago classification for esophageal motility disorders was designed fora 36-channel manometry system with sensors spaced at 1 cm. However, many motility labsoutside the United States use catheters with a lower resolution in the segments outside theesophagogastric junction. Aim: To investigate the effect of spatial resolution on the Chicagometrics and diagnosis. Methods: In 20 healthy volunteers and 47 patients with uppergastrointestinal symptoms, high-resolution manometric studies of the esophagus were retro-spectively re-analyzed using the original 1 cm spacing in the segments outside the 7 cmesophagogastric junction segment, and again after manually increasing the spacing betweensensors to 2, 3 and 4 cm (above the LES region). Measurements were analyzed in randomorder and the investigator was blinded to the outcome of the analyses performed in anotherresolution of the same patient. Intra-class correlation coefficients (ICC) and Kappa valueswere determined. Results: There was a very strong correlation between the 1 cm and 2 cmanalysis for all Chicago metrics studied in healthy volunteers (ICCs: distal contractile integral0.998; contractile front velocity 0.964; distal latency 0.919; peristaltic break size 0.941).The 2cm spacing analysis also correlated very well with the 1 cm analysis for the differentChicago diagnoses obtained in the patients (Kappa values ranging from 0.665 to 1.000).When the sensor spacing was increased to 3 and 4 cm the correlation was reduced tomoderate for the Chicago metrics (especially for break size and contractile front velocity ofperistalsis) and for the Chicago diagnoses. Conclusion: The Chicago classification for esopha-geal motility disorders is still valid and the same normal values can be used when catheterswith a slightly lower resolution are used. For larger sensor intervals, the classification andthe normal values will need to be adjusted.

Tu1991

Performance Characteristics of Distal Latency in the Diagnosis of Type 3Achalasia Using High Resolution Manometry (HRM)Ajay Sekhon, Elena Sidorenko, Amit Rastogi, Prateek Sharma, Ajay Bansal

Background: The manometric criteria for classification of type 3 achalasia continue to bedebated. Distal latency (DL) has been proposed as an important metric for its diagnosis butthe accuracy and the proposed landmarks for its measurements need further evaluation.Aims: a) To compare the sensitivity of DL measurements by two algorithms for diagnosisof systematically defined type 3 achalasia and b) To compare DL versus conduction velocityin defining spastic nature of type 3 achalasia Methods: Patients with achalasia were identifiedfrom a prospectively maintained HRM database. To test the performance of DL, type 3achalasia was defined by previously published criteria independent of DL. These were a)integrated relaxation pressure (IRP) > 15 mmHg and b) 20% of the swallows or greaterwith distal contractile integral (DCI) of >8,000 mmHg-s-cm. All ten swallows/patient weremeticulously reviewed with exclusion of double swallows. Using inbuilt measurement tools,DL was measured by two different algorithms: DL1 as the time elapsed between relaxationof the upper esophageal sphincter and the contractile deceleration point (CDP) and DL2 asthe time elapsed from the onset of contractile wavefront to CDP. DL1 and DL2 were labeledas abnormal if less than the previously proposed normative value of 4.5 s. Descriptivestatistics, t test and Pearson's correlation coefficients were used. Results: 141 swallows in15 patients (mean age 65 years, 90% males) with type 3 achalasia were evaluated, all with

S-892AGA Abstracts

dysphagia. Averages of manometric values for all 15 patients are presented in Table. MeanIRP and mean DCI were 25.7±12.4 mmHg and 12,430±11,511 mmHg-s-cm respectively.Mean DL1 and DL2 were 5.4±1.2 s and 4.3±1.1 s respectively (p=0.03). DL1 correctlyclassified only 13% of type 3 achalasia compared to 67% by DL2. Although conductionvelocity had a similar correlation with DL1 and DL2 (r= -0.49 (-0.37 to -0.60, p<0.0001)and -0.48 (-0.35 to -0.59, p<0.0001)) respectively, an abnormal value >9 cm/s correctlyclassified only 40% of the cases. If cases classified as type 3 achalasia based on DL2 alonewere considered, conduction velocity correctly identified 50% of the cases. Conclusion: DLcorrectly identifies a higher proportion of type 3 achalasia, when measured from the onsetof contractile wavefront to contractile deceleration point and performs better than the useof conduction velocity. Future studies need to further evaluate the best metric for the accurateclassification of type 3 achalasia.Table: Averages of manometric values for 15 patients

Tu1992

Intermittent Administration of Tadalafil Improves Esophageal Symptoms inAchalasic Patients.Guillermo Roberto Guevara-Morales, Enrique Perez Luna, Arturo Meixueiro, RafaelRojano-Gonzalez, Federico B. Roesch, Jose Maria Remes-Troche

Introduction and Aim: Achalasia is a primary motor disorder of the esophagus characterizedby abnormal lower esophageal sphincter relaxation and loss of esophageal peristalsis.Pneu-matic dilation or laparoscopic myotomy are recomended as first line therapy. Pharmacologicaltherapies are reserved for patients who cannot or refuse to undergo definitive therapies.However, the efficacy of medical therapy such as calcium channel blockers is low. Recently,we describe (DDW 2012) that tadalafil, a long half life 5-PDE (72 hrs), induce a prolongedand sustained effect on esophageal contractions and LEs relaxation in healthy humans. Ouraim in this study, was to evaluate the effects of intermittent tadalafil administration overthe LES pressure and the Integrated Relaxation Pressure (IRP) as well in symptoms in patientswith achalasia. Material and methods 12 patients, 6 men and 6 women with a mean ageof 44.13 ± 20 years were included. At baseline, in all subjects a high resolution manometry(Given, Yoqneam, Israel) was performed. Baseline HRM included 10 swallows of 5ml ofNaCl; then all subjects received 20 mgs of tadalafil (Cialis, LillyICOS, Washington, U.S.)and the catheter was left in place 2 hours. At 15, 30, 45, 60 and 120 minutes after thetadalafil dose, 5 swallows of 5 ml were performed. Blood pressure and heart rate wasrecorded continuously. 24 hours and 48 hours after de tadalafil dose, all subjects return tothe lab to repeat HRM. We measure LES, IRP and esophageal motility function accordingto the Chicago II classification parameters. After this evaluation patients received 20 mgstadalafil on demand (when symptoms reappear) and were evaluated every 2 weeks for 2months. Symptoms were evaluated using a Likert scale Results 6 patients had type 2Achalasia (50%), n = 3 (25%) type 1 Achalasia and n= 3 (25%) Type 3 Achalasia. Theaverages of parameters was evaluated before and after treatment, and showed statisticallysignificant differences (p = 0.02), specifically the IRP, and LES pressure. (Table) Dysphagiawas improved in 10 of 12 patients and duration of this improvement after Tadalafil treatmentwas averaged 3 days with range 1-5 days. Reported side effects were headache (60%) andback pain (20%). Conclusion Tadalafil may significantly reduced LES pressure and IRP inachalasia patients , and patients with Type 2 Achalasia had a better response . Tadalafilcould be a therapeutic option in patients with Achalasia, in which the surgery is notperformed immediately.