Correlation of radiographic and manometric findings in patients with ineffective esophageal motility
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- Shakespear, J., Blom, D., Huprich, J. et al. Surg Endosc (2004) 18: 459. doi:10.1007/s00464-003-8920-4
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Background: Ineffective esophageal motility disorder (IEM) is a new, manometrically defined, esophageal motility disorder, associated with severe gastroesophageal reflux disease (GERD), GERD-associated respiratory symptoms, delayed acid clearance, and mucosal injury. Videoesophagram is an important, inexpensive, and widely available tool in the diagnostic evaluation of patients with esophageal pathologies. The efficacy of videoesophagography has not been rigorously examined in patients with IEM. The aim of this study was to determine the diagnostic value of videoesophagography in patients with IEM. Methods: The radiographic and manometric findings of 202 consecutive patients presenting with foregut symptoms were evaluated. IEM was defined by strict manometric criteria. All other named motility disorders such as achalasia were excluded. Videoesophagography was performed according to a standard protocol. Results: Of patients in this cohort, 16% (33/202) had IEM by manometric criteria. Of IEM patients, 55% (18/33) had an abnormal videoesophagram, while in 45% (15/33) this test was read as normal. Only 11% (15/137) of patients with a normal videoesophagram were found to have IEM. Sensitivity of videoesophagram was 54.6%, specificity 72.2%, positive predictive value only 27.7%, and negative predictive value 89.1% in the diagnosis of IEM. Conclusions: These data show that videoesophagram is relatively insensitive in detecting patients with IEM and should not be considered a valid diagnostic test for this disorder. We conclude that esophageal manometry is an indispensable diagnostic modality in the workup of a patient with suspected of IEM.
KeywordsIneffective esophageal motilityBarium videoesophagramManometry
Esophageal function testing is becoming recognized as vital to the prediction of success and avoidance of complicatons after laparoscopic foregut surgery . In its Guidelines for surgical treatment of gastroesophageal reflux disease (GERD), the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) recommends that all patients receiving fundoplication undergo preoperative esophageal manometric evaluation . Esophageal function testing may discover previously unknown motility disorders, indicate the need for a modified surgical procedure, and suggest a significant risk of postoperative complications following fundoplication (i.e., recurrent GERD, dysphagia). The preoperative diagnosis of suspected motility disorders has taken on new relevance as it may have important implications in the choice of antireflux procedure performed.
Ineffective esophageal motility disorder (IEM) is the most recently described esophageal motility abnormality. Patients with IEM are a defined subset of individuals suffering from a hypocontractility syndrome who had previously been categorized as nonspecific esophageal motor disorder (NSEMD). IEM joins other named motility disorders including classic achalasia, atypical disorders of lower esophageal sphincter relaxation, diffuse esophageal spasm, nutcracker esophagus, and isolated hypertensive lower esophageal sphincter . This disorder was first described as a distinct category of esophageal motility disorder by Leite et al. in 1997 . Previous studies find that IEM is present in ~10% of patients presenting with foregut symptoms .
The manometric findings unique to IEM are functionally significant. IEM is associated with statistically significant increases in acid clearance times in the distal esophagus . Increased acid exposure in these patients is associated with the development of erosive esophagitis, stricture formation, Barrett’s esophagus, and GERD-associated respiratory symptoms [9, 11, 14].
The presence of IEM may also influence the selection of the appropriate antireflux operation, i.e., whether a 360° Nissen fundoplication or a partial fundoplication (Toupet procedure) is most appropriate [16, 19].
Esophageal manometry is the gold standard by which esophageal motility disorders are defined. It utilizes a series of pressure transducers placed in the esophagus to precisely record peristaltic activity. Unfortunately, manometry is not universally available and requires skilled technicians to administer and interpret. Because it requires a nasogastric tube, manometry is more invasive and less well tolerated by patients.
In addition to manometry, SAGES recommends barium esophagram in select patients with foregut symptoms. It has long been an important part of the diagnostic evaluation of anatomic abnormalities such as luminal compromise secondary to stricture or tumor, hiatal hernia, and diverticula. Recent studies have shown its value in imaging functional abnormalities as well . For example, Fuller et al. recently found that videoesophagram has a high sensitivity and specificity in disorders such as achalasia and scleroderma . It is inexpensive, well tolerated, more widely available, and less invasive than esophageal manometry.
To date, the efficacy of videoesophagography has not been rigorously examined in patients with IEM. Because videoesophagography is inexpensive, well tolerated, widely available, and less invasive than esophageal manometry, the aim of this study was to determine the diagnostic value of videoesophagography in patients with manometrically proven ineffective esophageal motility.
Materials and methods
Esophageal manometric studies and barium videoesophagography were prospectively collected and compared in 202 patients presenting with foregut symptoms. All patients were seen in the University of Southern California Esophageal Function Laboratory and the University of Southern California University Hospital Department of Radiology between April 1997 and May 1998.
Esophageal manometry testing was performed according to a standard protocol using a low compliance pneumohydraulic perfusion system consisting of an eight-lumen catheter as described previously . Esophageal body function was assessed with the most proximal pressure transducer 1 cm below the cricopharyngeal sphincter and the transducers distal to it trailing at 5-cm intervals along the entire length of the esophagus.
Ineffective esophageal motility was defined manometrically as nontransmitted contractions or distal esophageal amplitudes measuring <30 mmHg seen in >30% of wet swallows. Patients with low-amplitude, simultaneous contractions characteristic of achalasia were excluded from the IEM group.
Barium videoesophagography was performed according to a standard protocol. Patients were placed in a prone oblique position to best visualize esophageal body function. Each patient was requested to swallow five 10-cc boluses of 60% weight/volume barium sulfate suspension at room temperature. A time interval of 10–20 sec between swallows was observed. The patients were asked to swallow the entire bolus and not divide it into smaller swallows. They were also requested to refrain from swallowing between boluses to minimize any deglutitive inhibition. When a patient complied with both of these instructions a swallow was considered diagnostic. Only diagnostic swallows were evaluated. If a swallow was recognized as not diagnostic, additional swallows were given to make a total of five diagnostic swallows. Videofluoroscopic recording was carried out for each swallow using a 15-inch image-intensifying system to visualize the entire length of the esophagus.
A single gastrointestinal radiologist (J.E.H.), blinded to the manometric findings, read all videosesophagrams. The barium examination was considered abnormal if stasis of contrast was noted in the distal third of the esophageal body on three or more of the five swallows or on four or more of the five swallows in the middle third of the esophagus. Abnormal stasis was defined as an opaque column of contrast sufficient to obscure visualization of the mucosal folds and overlying structures. Smaller amounts of residual barium not completely cleared by a peristaltic wave were considered normal.
The sensitivity, specificity, and positive and negative predictive values were calculated to assess the diagnostic value of videoesophagram. Comparison was made with manometry as the gold standard. Sensitivity was defined as the true positives divided by the sum of true positives and false negatives. True negatives divided by the sum of false positives and true negatives defined specificity. Positive and negative predictive values were calculated to measure the percentage of videoesophagram test results that match the actual manometric diagnosis.
The study population consisted of 90 women and 112 men, with a median age of 52 years (range, 18–88). There was a median time interval between the videoesophagram and manometric examination of 16 days (range, 0–284). Primary symptoms necessitating evaluation included heartburn (46%), dysphagia (19%), chest or epigastric pain (12%), respiratory symptoms (7%), regurgitation (5%), bloating, nausea, or vomiting (5%), and other symptoms (6%). The IEM patient population consisted of 17 women and 16 men. Primary symptoms in this group of 33 patients included heartburn (48%), dysphagia (18%), chest or epigastric pain (12%), respiratory symptoms (12%), regurgitation (3%), bloating, nausea, or vomiting (0%), and other symptoms (7%) (Fig. 1).
Of patients in this cohort, 16% (33/202) were diagnosed with ineffective esophageal motility disorder (IEM) by manometric criteria. Of these, 55% (18/33) also had an abnormal videoesophagram. In 45% (15/33) of patients with IEM the videoesophagram was read as normal. Of the 137 patients found to have a normal videoesophagram, 15 (11%) were also found to have IEM (Fig. 2). These results translated into a sensitivity of 54.6%, a specificity of 72.2% for videoesophagram in the diagnosis of IEM. Furthermore, videoesophagram has a positive predictive value of only 27.7% and a negative predictive value of 89.1% in the diagnosis of IEM. These data are summarized in Table 1.
Ineffective esophageal motility disorder (IEM) is a recently defined distinct esophageal motility abnormality associated with severe GERD. IEM is characterized by profound hypocontractility in the distal esophagus as measured by manometry. More specifically, this disorder is defined by distal esophageal contraction amplitudes <30 mmHg or nontransmitted contractions in <30% of wet swallows. Kahrilas et al.  noted increasing peristaltic dysfunction with increasing severity of esophagitis and retrograde bolus movement when esophageal contraction amplitudes were ≤ 25 mmHg. These observations correlate well with the findings commonly observed in IEM patients, which include statistically significant increases in acid clearance times in the distal esophagus, the development of erosive esophagitis, stricture formation, Barrett’s esophagus, and GERD-associated respiratory symptoms [9, 11, 14, 17].
The mucosal damage observed in patients with severe, long-term IEM provides strong incentive to diagnose this disorder early in order not only to relieve the GERD symptoms associated with IEM but also to allow for mucosal healing and prevent further esophageal damage and complications such as stricture formation or Barrett’s metaplasia. At this time, it is unclear whether gastroesophageal reflux leads to the development of IEM by repeated distal esophageal acid exposure. It is clear, however, that whatever the pathogenesis, this process appears irreversible . Most studies indicate that optimal medical control of reflux fails to produce improvement in peristaltic amplitude .
IEM was first described as a distinct category of esophageal motility disorder by Leite et al. after reviewing the manometric tracings of 599 wet swallows in 61 patients previously given the manometric diagnosis of nonspecific esophageal motility disorder (NEMD). NEMD is a vague category used to include patients with poorly defined esophageal motility that do not have the features of a named disorder. Sixty of the 61 patients (98%) had distal esophageal contraction amplitudes of <30 mmHg or nontransmitted contractions in >30% of swallows. Because these 60 patients were found to have these specific hypocontractile manometric findings they were considered to belong to a new subcategory named ineffective esophageal motility disorder (IEM). It was recommended that IEM replace NEMD. Previous studies find that IEM is present in ~10% of patients presenting with foregut symptoms .
The current study compared the radiologic and manometric data of 202 patients presenting to a tiertiary esophageal referral center with foregut symptoms. The group of 33 IEM patients extracted from this larger pool of 202 is, to our knowledge, currently the largest population yet published with both radiologic and manometric studies. Videoesophagram was found to have a sensitivity of only 54.6% and specificity of 72.2% in the diagnosis of IEM. It, therefore, is a relatively poor diagnostic test for this disorder. These results are consistent with previous studies that show videoesophagram to have a low sensitivity in patients with manometrically defined diffuse esophageal spasm and nonspecific esophageal motility disorder [6, 12].
The prevalence of IEM in our patient population (16%) is higher than that reported in other studies (~10%) . This may be explained by an increase in the prevalence of patients presenting with more severe disease at our tertiary esophageal center where this database was compiled. This subtle increase in prevalence may have affected the negative predictive value of our study. A diagnostic test performed in a population with a low prevalence of a disease will have a higher negative predictive value than the same test in populations with a higher prevalence. Therefore our negative predictive value of 89.1% may be lower than would be seen in the general population.
The result, however, that a normal videoesophagram effectively rules out IEM, is similar to a recent study by Fuller et al. that also found a strong negative predictive value for videoesophagram in achalasia and scleroderma .
Interestingly, we found that although the esophageal hypocontractility in IEM may be sufficient to produce statistically significant increases in acid clearance times, it is insufficient to cause consistent abnormalities in the videoesophagram. This supports previous findings that barium esophagram is much less sensitive than prolonged pH monitoring for identifying reflux [6, 23].
Finally, many have long advocated the use of partial fundoplication in patients with esophageal dysmotility because of the belief that a Nissen fundoplication may lead to unacceptable rates of postoperative dysphagia [10, 18]. However, recent data indicate that a Nissen fundoplication may provide more durable, effective, and long-lasting amelioration of gastroesophageal reflux in patients with disordered esophageal motility without significant increases in postoperative dysphagia [3, 13]. In a recent study of the factors contributing to long-term success and failure of laparoscopic modified Toupet fundoplication, Bell et al.  found that ineffective peristalsis associated with severe reflux esophagitis was a strong predictor of partial fundoplication failure. In fact, the presence of either severe esophagitis or a hypocontractile distal esophagus was associated with a 3-year success rate of only 50% in the 143 patients studied. The authors recommended that instead of being reserved for instances of ineffective peristalsis in which failure is likely, the Toupet procedure should be employed in cases of objectively milder disease, i.e., the presence of normal distal esophageal motility and the absence of complicated esophagitis .
Videoesophagram is relatively insensitive in detecting patients with IEM and should not be considered a valid diagnostic test for this disorder. However, despite the lack of sensitivity of videoesophagram, its relatively high negative predictive value provides some level of confidence that a patient with a normal videoesophagram does not have IEM. We believe, however, that manometry is essential in any patient with suspected IEM and especially important in the patient with GERD. This is due to the fact that IEM is the most common motility disorder in patients presenting with GERD, is associated with more severe GERD and GERD-related respiratory symptoms, and may be important in the selection of an antireflux procedure [9, 11].