811 WHETHER 10 WATER SWALLOWS NECESSARY TO OBTAIN REPRODUCIBLE RESULTS OF HIGH-RESOLUTION OESOPHAGEAL MANOMETRY?

Not less than ten wet swallows assessment in the primary test position is recommended by Chicago classification 4.0 for high-resolution oesophageal manometry (HREM); however, the required number of measurements are not sufficiently supported. Aim to evaluate the number of wet swallows necessary for correct interpretation of the results of lower esophageal sphincter integrated relaxation pressure (IRP) with low probability of type I and II errors. Methods Patients referred to perform HREM were enrolled. Solid-state 10Fr catheter and Solar (Laborie) software were used. Minimum 10 swallows by 5 mL water were obtained. These were analysed for cumulative means of IRP after 1…9 measurements. Conclusion made at each moment was compared with one based on 10 measurements. The results were characterized as true/false positive/negative for calculation of diagnostic accuracy. To exclude sample influence, Monte-Carlo simulation of sequential decision-making was performed with the use of sequential probability ratio test. Association of the diagnostic accuracy from recall was studied with the use of receiver operating characteristic curve (ROC) analysis. Results One hundred subjects were enrolled (25 with disorders of EGJ outflow). During the simulation, the probability of matching the decisions based on the 10 measurements and lower number of them was high. ROC analysis showed that actual probability to obtain false-positive results was twice as lower then ‘allowed’ rate of 5%. The probability to make false-negative results did not exceed 10% in any number of measurements. The probability that the conclusions made after 2 and after 10 measurements match was 0.9584 in those with disorders of EGJ outflow and 0.9652 in those without (figure 1). Conclusion The standard number of measurements required to support the presence of disorders of EGJ outflow during evaluation of 5 mL wet swallows in the primary position is excessive. Values of the IRP after 2 swallows allows to make similar decision to that after 10 swallows with >95% probability. This allows to reduce the number of wet swallows to assess in the primary position and save time for assessments in alternative position or perform provocation tests.

Guidance on performance and reporting of high-resolution oesophageal manometry and ambulatory pH monitoring in Singapore

Introduction: We aimed to provide a practical and evidence-based guide on the indications, performance and reporting of high-resolution oesophageal manometry (HRM) and ambulatory pH monitoring (PHM) in adult patients in Singapore. Methods: The guideline committee comprised local gastroenterologists from public and private sectors with particular expertise in aspects of HRM and PHM, and it was tasked to produce evidence-based statements on the indications, performance and reporting of these tests. Each committee member performed literature searches to retrieve relevant articles within the context of domains to which they were assigned. Results: Twelve recommendation statements were created and summarised. Conclusion: Standardising key aspects of HRM and PHM is imperative to ensure the delivery of high-quality care. We reported the development of recommendations for the performance and interpretation of HRM and ambulatory reflux monitoring in Singapore. Keywords: Gastro-oesophageal reflux disease, GERD, high-resolution oesophageal manometry, oesophagus, pH testing

Reflux aspiration associated with oesophageal dysmotility but not delayed liquid gastric emptying

Introduction Severe oesophageal dysmotility is associated with treatment resistant reflux and pulmonary reflux aspiration. Delayed solid gastric emptying (SGE) has been associated with oesophageal dysmotility, however the role of delayed liquid gastric emptying (LGE) in the pathophysiology of severe reflux disease remains unknown. The purpose of this study is to examine the relationship between delayed LGE, reflux aspiration and oesophageal dysmotility. Methods Data was extracted from a prospectively populated database of patients with severe treatment resistant gastro-oesophageal reflux disease (GORD). All patients with validated reflux aspiration scintigraphy (RASP) and oesophageal manometry were included in the analysis. Patients were classified by predominant clinical subtype as gastro-oesophageal (GOR) or laryngo-pharyngeal (LPR) reflux. LGE time of 22 minutes or longer was considered delayed. Results Inclusion criteria were met by 631 patients. Normal LGE time was found in 450 patients, whilst 181 had evidence of delayed LGE. Mean liquid half-clearance was 22.81min. Refux aspiration was evident in 240 patients (38%). Difference in the aspiration rates between delayed LGE (42%) and normal LGE (36%) was not significant (p=0.16). Severe ineffective oesophageal motility (IOM) was found in 70 patients (35%) and was independent of LGE time. Severe IOM was strongly associated with reflux aspiration (p<0.001). GOR dominant symptoms were more common in patients with delayed LGE (p=0.03). Conclusion Severe IOM was strongly associated with reflux aspiration. Delayed LGE is not associated with reflux aspiration or severe IOM. Delayed LGE is more prevalent in patients presenting with GOR dominant symptoms.

British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring

These guidelines on oesophageal manometry and gastro-oesophageal reflux monitoring supersede those produced in 2006. Since 2006 there have been significant technological advances, in particular, the development of high resolution manometry (HRM) and oesophageal impedance monitoring. The guidelines were developed by a guideline development group of patients and representatives of all the relevant professional groups using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. A systematic literature search was performed and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tool was used to evaluate the quality of evidence and decide on the strength of the recommendations made. Key strong recommendations are made regarding the benefit of: (i) HRM over standard manometry in the investigation of dysphagia and, in particular, in characterising achalasia, (ii) adjunctive testing with larger volumes of water or solids during HRM, (iii) oesophageal manometry prior to antireflux surgery, (iv) pH/impedance monitoring in patients with reflux symptoms not responding to high dose proton pump inhibitors and (v) pH monitoring in all patients with reflux symptoms responsive to proton pump inhibitors in whom surgery is planned, but combined pH/impedance monitoring in those not responsive to proton pump inhibitors in whom surgery is planned. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG.

Distal oesophageal spasm secondary to eosinophilic oesophagitis in a child: response to diet therapy

We report a case of a school-age child with symptomatic distal oesophageal spasm (DES), clinical dysphagia and typical feature in high-resolution oesophageal manometry secondary to eosinophilic oesophagitis (EoE). His symptoms resolved with normalisation of oesophageal manometry after standard treatment of EoE. DES is mainly an adult disorder and rarely affect children; to the best of our knowledge, this is the first reported case in a child that document full recovery after treating the underlying EoE.