Hiestand Mirjam, Abdel Jalil Ala', Castell Donald O
Division of Gastroenterology & Hepatology, Hospital of Graubünden, Chur, Switzerland.
Division of Gastroenterology & Hepatology, University of Missouri-Columbia, Columbia, Missouri, USA.
Clin Transl Gastroenterol. 2017 Mar 9;8(3):e78. doi: 10.1038/ctg.2017.4.
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).
A total of 231 IEM patients were identified by high-resolution manometry (HRM). IEM defined by distal contractile integral (DCI) <450 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.
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).
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.
无效食管动力（IEM）以明确的测压标准为特征。然而，在诊断过程中存在很大差异：一些患者恰好表现出诊断所需的五次微弱吞咽。另一些患者则持续表现为无效吞咽，完全没有任何正常吞咽。“我们推测”IEM存在两种不同的测压亚型；交替性IEM（IEM-A）和持续性IEM（IEM-P）。
通过高分辨率测压（HRM）确定了231例IEM患者。IEM定义为在≥50%的测试吞咽中远端收缩积分（DCI）<450mmHg/s/cm。异常反流研究定义为反流发作总数过多、食管酸暴露异常或症状关联阳性。
共有195例（84%）患者为IEM-A，36例（16%）为IEM-P。存在显著的性别差异，IEM-A患者中男性占34%，而IEM-P患者中男性占53%。（P=0.03）。IEM-P的平均年龄（59.6岁±13.1）大于IEM-A（55.5岁±13.6）（P=0.04）。IEM-P的平均食管下括约肌（LES）静息压力（20.8mmHg±1.4）显著低于IEM-A（29mmHg±1.2）（P=0.002）。两组之间LES综合松弛压力（IRP）、食团通过情况或食管裂孔疝的测压表现无差异。在146例患者中，89例（61%）有异常反流研究。IEM-P患者直立位食管酸暴露显著高于IEM-A（3.5%对1.7%，P=0.04）。IEM-P患者中质子泵抑制剂（PPI）治疗下胃酸控制不佳的情况（58%）比IEM-A患者（27%）更普遍（P=0.007）。在对41例有吞咽困难的IEM患者进行的亚组分析中，IEM-P患者液体吞咽的DCI（111±142mmHg/s/cm）显著低于IEM-A（421±502mmHg/s/cm）（P=0.04），IEM-P的平均LES静息压力（16.6±9mmHg）低于IEM-A（31.7±18mmHg）（P=0.01）。
存在两种不同的测压IEM亚型；IEM-P以老年男性为主，反流疾病更严重，LES更弱，对PPI反应更差；可能是比IEM-A更晚期的表现。然而，这两种亚型是否存在不同病因的问题仍有待解答。
