Quader Farhan, Reddy Chanakyaram, Patel Amit, Gyawali C Prakash
Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri.
Division of Gastroenterology University of Michigan School of Medicine, Ann Arbor, Michigan; and.
Am J Physiol Gastrointest Liver Physiol. 2017 Jul 1;313(1):G73-G79. doi: 10.1152/ajpgi.00091.2017. Epub 2017 Apr 13.
Elevated integrated relaxation pressure (IRP) on esophageal high-resolution manometry (HRM) identifies obstructive processes at the esophagogastric junction (EGJ). Our aim was to determine whether intrabolus pressure (IBP) can identify structural EGJ processes when IRP is normal. In this observational cohort study, adult patients with dysphagia and undergoing HRM were evaluated for endoscopic evidence of structural EGJ processes (strictures, rings, hiatus hernia) in the setting of normal IRP. HRM metrics [IRP, distal contractile integral (DCI), distal latency (DL), IBP, and EGJ contractile integral (EGJ-CI)] were compared among 74 patients with structural EGJ findings (62.8 ± 1.6 yr, 67.6% women), 27 patients with normal EGD (52.9 ± 3.2 yr, 70.3% women), and 21 healthy controls (27.6 ± 0.6 yr, 52.4% women). Findings were validated in 85 consecutive symptomatic patients to address clinical utility. In the primary cohort, mean IBP (18.4 ± 0.9 mmHg) was higher with structural EGJ findings compared with dysphagia with normal EGD (13.5 ± 1.1 mmHg, = 0.002) and healthy controls (10.9 ± 0.9 mmHg, < 0.001). However, mean IRP, DCI, DL, and EGJ-CI were similar across groups ( > 0.05 for each comparison). During multiple rapid swallows, IBP remained higher in the structural findings group compared with controls ( = 0.02). Similar analysis of the prospective validation cohort confirmed IBP elevation in structural EGJ processes, but correlation with dysphagia could not be demonstrated. We conclude that elevated IBP predicts the presence of structural EGJ processes even when IRP is normal, but correlation with dysphagia is suboptimal. Integrated relaxation pressure (IRP) above the upper limit of normal defines esophageal outflow obstruction using high-resolution manometry. In patients with normal IRP, elevated intrabolus pressure (IBP) can be a surrogate marker for a structural restrictive or obstructive process at the esophagogastric junction (EGJ). This has the potential to augment the clinical value of esophageal HRM by raising suspicion for a structural EGJ process when IBP is elevated.
食管高分辨率测压（HRM）时综合松弛压（IRP）升高可识别食管胃交界（EGJ）处的梗阻性病变。我们的目的是确定当IRP正常时，团注内压（IBP）是否能识别EGJ的结构性病变。在这项观察性队列研究中，对有吞咽困难且正在接受HRM检查的成年患者进行评估，以寻找在IRP正常情况下EGJ结构性病变（狭窄、环、食管裂孔疝）的内镜证据。比较了74例有EGJ结构性病变的患者（62.8±1.6岁，67.6%为女性）、27例食管胃镜检查正常的患者（52.9±3.2岁，70.3%为女性）和21名健康对照者（27.6±0.6岁，52.4%为女性）的HRM指标[IRP、远端收缩积分（DCI）、远端潜伏期（DL）、IBP和EGJ收缩积分（EGJ-CI）]。在85例连续的有症状患者中对结果进行验证以评估临床实用性。在主要队列中，有EGJ结构性病变患者的平均IBP（18.4±0.9 mmHg）高于食管胃镜检查正常的吞咽困难患者（13.5±1.1 mmHg，P = 0.002）和健康对照者（10.9±0.9 mmHg，P < 0.001）。然而，各组间平均IRP、DCI、DL和EGJ-CI相似（每项比较P>0.05）。在多次快速吞咽期间，有结构性病变组的IBP仍高于对照组（P = 0.02）。对前瞻性验证队列的类似分析证实了EGJ结构性病变中IBP升高，但无法证明其与吞咽困难的相关性。我们得出结论，即使IRP正常，IBP升高也可预测EGJ存在结构性病变，但与吞咽困难的相关性欠佳。正常上限以上的综合松弛压（IRP）使用高分辨率测压法定义食管流出道梗阻。在IRP正常的患者中，升高的团注内压（IBP）可能是食管胃交界（EGJ）处结构性狭窄或梗阻性病变的替代标志物。当IBP升高时，这有可能通过提高对EGJ结构性病变的怀疑来增加食管HRM的临床价值。
