Balko Ryan A, Codipilly Don C, Ravi Karthik
Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
Curr Treat Options Gastroenterol. 2020 Jan 17;18(1):82-96. doi: 10.1007/s11938-020-00279-x. Print 2020 Mar.
High resolution esophageal manometry (HRM) has expanded understanding of esophageal motor function. The Chicago Classification scheme has allowed systematic categorization of the myriad of manometric parameters identified during HRM. Multichannel intraluminal impedance pH has enhanced ambulatory reflux monitoring through complete assessment of esophageal content transit. However, the clinical implications of identified minor esophageal functional disorders remain unclear.
Esophagogastric junction outlet obstruction is defined by esophagogastric junction obstruction with preserved peristalsis and may be managed expectantly, or in a manner similar to achalasia. Hypercontractile esophagus has been associated with dysphagia and non-cardiac chest pain, but the clinical significance is unclear as a majority of patients will improve without specific therapy. Additionally, these findings may be confounded by chronic opiate use. Ineffective esophageal motility is characterized by diminished esophageal contraction amplitude, potentially causing dysphagia and GERD. However, this is commonly identified in asymptomatic volunteers and may represent a normal variant. The multiple rapid swallow sequence can assess esophageal contraction reserve, which may predict post fundoplication dysphagia. The post-swallow induced peristaltic wave can serve as a surrogate of gastric refluxate clearance, providing important prognostic value. However, the associated time burden and lack of alternative therapeutic options limit its clinical utility.
Minor esophageal functional disorders provide new therapeutic targets for symptomatic patients. However, these findings have inconsistent associations with symptoms and poorly defined therapeutic options. Minor esophageal function disorders should not be interpreted in isolation, with management decisions accounting for clinical, endoscopic, and radiographic factors in addition.
高分辨率食管测压（HRM）扩展了对食管运动功能的认识。芝加哥分类方案允许对HRM期间识别出的众多测压参数进行系统分类。多通道腔内阻抗pH监测通过对食管内容物传输的全面评估增强了动态反流监测。然而，已识别的轻度食管功能障碍的临床意义仍不明确。
食管胃交界部出口梗阻定义为食管胃交界部梗阻且蠕动保留，可进行观察性处理，或采用与贲门失弛缓症类似的方式处理。高收缩性食管与吞咽困难和非心源性胸痛有关，但由于大多数患者无需特殊治疗即可改善，其临床意义尚不清楚。此外，这些发现可能会因长期使用阿片类药物而混淆。无效食管动力的特征是食管收缩幅度减小，可能导致吞咽困难和胃食管反流病（GERD）。然而，这在无症状志愿者中很常见，可能代表一种正常变异。多次快速吞咽序列可评估食管收缩储备，这可能预测胃底折叠术后的吞咽困难。吞咽后诱发的蠕动波可作为胃反流物清除的替代指标，具有重要的预后价值。然而，相关的时间负担和缺乏替代治疗选择限制了其临床应用。
轻度食管功能障碍为有症状的患者提供了新的治疗靶点。然而，这些发现与症状的关联不一致，治疗选择也不明确。轻度食管功能障碍不应孤立地解释，管理决策还应考虑临床、内镜和影像学因素。
