Critical Analysis of Esophageal Multichannel Intraluminal Impedance Monitoring 20 Years Later

Herbella, Fernando A M

doi:10.5402/2012/903240

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Critical Analysis of Esophageal Multichannel Intraluminal Impedance Monitoring 20 Years Later

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Author(s): Fernando A. M. Herbella ¹ ^, ² ^, ^*

Publication date (Electronic): 24 October 2012

Journal: ISRN Gastroenterology

Publisher: International Scholarly Research Network

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Abstract

Multichannel intraluminal impedance (MII) for the evaluation of esophageal diseases was created in 1991 trying to solve previous limitations of esophageal function test. MII-pH is able to determine the physical characteristics of the refluxate (liquid, gas, or mixed) and nonacidic GER. MII-manometry can determine the presence of bolus and its relation with peristalsis. This paper makes a critical analysis of the clinical applications of MII 20 years after its creation. Literature review shows that MII made great contributions for the understanding of esophageal physiology; however, direct clinical applications are few. MII-pH was expected to identify patients with normal acid reflux and abnormal nonacidic reflux. These patients are rarely found off therapy, that is, nonacidic reflux parallels acid reflux. Furthermore, the significance of isolated nonacidic reflux is unclear. Contradictory MII-manometry and conventional manometry findings lack better understanding and clinical implication as well as the real significance of bolus transit.

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Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography.

André Smout, Peter Kahrilas, John E Pandolfino … (2012)

The Chicago Classification of esophageal motility was developed to facilitate the interpretation of clinical high resolution esophageal pressure topography (EPT) studies, concurrent with the widespread adoption of this technology into clinical practice. The Chicago Classification has been an evolutionary process, molded first by published evidence pertinent to the clinical interpretation of high resolution manometry (HRM) studies and secondarily by group experience when suitable evidence is lacking. This publication summarizes the state of our knowledge as of the most recent meeting of the International High Resolution Manometry Working Group in Ascona, Switzerland in April 2011. The prior iteration of the Chicago Classification was updated through a process of literature analysis and discussion. The major changes in this document from the prior iteration are largely attributable to research studies published since the prior iteration, in many cases research conducted in response to prior deliberations of the International High Resolution Manometry Working Group. The classification now includes criteria for subtyping achalasia, EGJ outflow obstruction, motility disorders not observed in normal subjects (Distal esophageal spasm, Hypercontractile esophagus, and Absent peristalsis), and statistically defined peristaltic abnormalities (Weak peristalsis, Frequent failed peristalsis, Rapid contractions with normal latency, and Hypertensive peristalsis). The Chicago Classification is an algorithmic scheme for diagnosis of esophageal motility disorders from clinical EPT studies. Moving forward, we anticipate continuing this process with increased emphasis placed on natural history studies and outcome data based on the classification. © 2012 Blackwell Publishing Ltd.

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Achalasia: a new clinically relevant classification by high-resolution manometry.

John E Pandolfino, Monika A Kwiatek, Thomas Nealis … (2008)

Although the diagnosis of achalasia hinges on demonstrating impaired esophagogastric junction (EGJ) relaxation and aperistalsis, 3 distinct patterns of aperistalsis are discernable with high-resolution manometry (HRM). This study aimed to compare the clinical characteristics and treatment response of these 3 subtypes. One thousand clinical HRM studies were reviewed, and 213 patients with impaired EGJ relaxation were identified. These were categorized into 4 groups: achalasia with minimal esophageal pressurization (type I, classic), achalasia with esophageal compression (type II), achalasia with spasm (type III), and functional obstruction with some preserved peristalsis. Clinical and manometric variables including treatment response were compared among the 3 achalasia subtypes. Logistic regression analysis was performed using treatment success as the dichotomous dependent variable controlling for independent manometric and clinical variables. Ninety-nine patients were newly diagnosed with achalasia (21 type I, 49 type II, 29 type III), and 83 of these had sufficient follow-up to analyze treatment response. Type II patients were significantly more likely to respond to any therapy (BoTox [71%], pneumatic dilation [91%], or Heller myotomy [100%]) than type I (56% overall) or type III (29% overall) patients. Logistic regression analysis found type II to be a predictor of positive treatment response, whereas type III and pretreatment esophageal dilatation were predictive of negative treatment response. Achalasia can be categorized into 3 subtypes that are distinct in terms of their responsiveness to medical or surgical therapies. Utilizing these subclassifications would likely strengthen future prospective studies of treatment efficacy in achalasia.

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Esophageal pH-impedance monitoring and symptom analysis in GERD: a study in patients off and on therapy.

Sabine Roman, Philippe Pouderoux, Stanislas Bruley des Varannes … (2006)

Combined esophageal pH-impedance monitoring allows detection of nearly all gastroesophageal reflux episodes, acid as well as nonacid. However, the role of nonacid reflux in the pathogenesis of symptoms is poorly known. The aim of this study was to evaluate the diagnostic yield of this technique in patients with suspected reflux symptoms while on or off PPI therapy. The recordings of 150 patients recruited at seven academic centers with symptoms possibly related to gastroesophageal reflux were analyzed. Reflux events were detected visually using impedance (Sandhill, CO) and then characterized by pHmetry as acid or nonacid reflux. The temporal relationship between symptoms and reflux episodes was analyzed: a symptom association probability (SAP) > or =95% was considered indicative of a positive association. One hundred fifty patients were included, 102 women (mean age 52 +/- 14 yr, range 16-84). Among the 79 patients off PPI, five did not report any symptom during the recording period. A positive SAP was found in 41 of the 74 symptomatic patients (55.4%), including acid reflux in 23 (31.1%), nonacid reflux in three (4.1%), and acid and nonacid in 15 (20.3%). In the group of patients on PPI (N = 71, 46 women, mean age 51 +/- 15 yr), 11 were asymptomatic during the study, SAP was positive in 22 of the 60 symptomatic patients (36.7%), including acid reflux in three (5.0%), nonacid reflux in 10 (16.7%), and acid and nonacid in nine (15.0%). The symptoms most frequently associated with nonacid reflux were regurgitation and cough. Adding impedance to pH monitoring improves the diagnostic yield and allows better symptom analysis than pHmetry alone, mainly in patients on PPI therapy. The impact of this improved diagnostic value on gastroesophageal reflux disease management remains to be investigated by outcome studies.

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Author and article information

Journal

Journal ID (nlm-ta): ISRN Gastroenterol

Journal ID (iso-abbrev): ISRN Gastroenterol

Journal ID (publisher-id): ISRN.GASTROENTEROLOGY

Title: ISRN Gastroenterology

Publisher: International Scholarly Research Network

ISSN (Print): 2090-4398

ISSN (Electronic): 2090-4401

Publication date Collection: 2012

Publication date (Electronic): 24 October 2012

Volume: 2012

Electronic Location Identifier: 903240

Affiliations

¹Department of Surgery, São Paulo Medical School, Federal University of São Paulo, 04021-001 São Paulo, SP, Brazil

²Surgical Gastroenterology, Division of Esophagus and Stomach, Hospital São Paulo, Rua Diogo de Faria 1087 cj 301, 04037-003 São Paulo, SP, Brazil

Author notes

*Fernando A. M. Herbella: herbella.dcir@ 123456epm.br

Academic Editors: G. H. Kang, A. Nakajima, and C.-T. Shun

Article

DOI: 10.5402/2012/903240

PMC ID: 3488400

PubMed ID: 23150831

SO-VID: 8eec3d89-7f52-4a16-87a9-e5ade6c07c56

License:

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Critical Analysis of Esophageal Multichannel Intraluminal Impedance Monitoring 20 Years Later

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Most cited references 87

Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography.

Achalasia: a new clinically relevant classification by high-resolution manometry.

Esophageal pH-impedance monitoring and symptom analysis in GERD: a study in patients off and on therapy.

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