Peter J Kahrilas

• M.D.
• Professor at Northwestern University

Background & aims: Eosinophilic esophagitis (EoE) is characterized by eosinophilic inflammation, but also heterogeneous presentations involving fibrostenotic esophageal remodeling and esophageal dysmotility. We aimed to define and evaluate phenotypes of EoE using functional lumen imaging probe (FLIP) Panometry, i.e. a PhysioMechanical Classificati...

Background & aims: Chronic inflammation of eosinophilic esophagitis (EoE) results in progressive, fibrostenotic remodeling of the esophageal wall. This study aimed to demonstrate objective changes in esophageal distensibility relative to duration of EoE disease using functional lumen imaging probe (FLIP). Methods: Adult patients with EoE who com...

Background An association of eosinophilic esophagitis (EoE) with esophageal dysmotility has been described, however the related mechanism remains unclear. We aimed to evaluate clinical and physiologic characteristics, including esophageal distensibility, associated with secondary peristalsis in patients with EoE. Methods 199 consecutive adult pati...

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodolo...

Proton pump inhibitor (PPI) therapy is commonly used outside of Food and Drug Administration indication for a broad range of conditions such as extra-esophageal reflux and PPI-responsive esophageal eosinophilia. While this may be appropriate in some scenarios, it has also resulted in widespread inappropriate PPI use. At the same time, data suggesti...

Background: Increased esophagogastric junction (EGJ) distensibility is thought to contribute to gastroesophageal reflux disease (GERD). Using the functional lumen imaging probe (FLIP), we aimed to assess the esophageal response to distension among patients undergoing esophageal pH monitoring. Methods: 25 patients (ages 22-73; 13 females) who und...

Background and aims We recently developed 2 novel 3D high‐resolution manometry (HRM) metrics of esophagogastric junction (EGJ) contractility to differentiate the lower esophageal sphincter (LES) and crural diaphragm (CD) elements of EGJ pressure. This study aimed to compare these metrics to the EGJ‐contractile integral (EGJ‐CI) and to analyze their...

Background: The Chicago Classification v3.0 proposed extending the distal contractile integral (DCI) measurement domain to include the lower esophageal sphincter (LES) to enhance the detection of esophageal hypercontractility. However, normative and clinical data for this approach are unreported. We aimed to describe the application of an extended...

en Linked Content This article is linked to Ponds et al paper. To view this article visit https://doi.org/10.1111/apt.14057.

Based on a fully coupled computational model for esophageal transport, we analyzed the role of the mucosa (including the submucosa) in esophageal bolus transport and how bolus transport is affected by mucosal stiffness. Two groups of studies were conducted using a computational model. In the first group, a base case that represents normal esophagea...

Background: Based on a fully coupled computational model of esophageal transport, we analyzed how varied esophageal muscle fiber architecture and/or dual contraction waves (CWs) affect bolus transport. Specifically, we studied the luminal pressure profile in those cases to better understand possible origins of the peristaltic transition zone. Met...

Background: Competent interpretation of esophageal high-resolution manometry (HRM) is integral to a quality study. Currently, methods to assess physician competency for the interpretation of esophageal HRM do not exist. The aim of this study was to use formal techniques to (i) develop an HRM interpretation exam, and (ii) establish minimum competen...

Background: We updated the 2006 ACCP clinical practice guidelines for management of reflux-cough syndrome. Methods: Two PICO questions were addressed by systematic review: 1) can therapy for gastroesophageal reflux improve or eliminate cough in adults with chronic and persistently troublesome cough? and 2) are there minimal clinical criteria to...

Background: High-resolution impedance manometry (HRIM) allows evaluation of esophageal bolus retention, flow, and pressurization. We aimed to perform a collaborative analysis of HRIM metrics to evaluate patients with non-obstructive dysphagia. Methods: Fourteen asymptomatic controls (58% female; ages 20-50) and 41 patients (63% female; ages 24-8...

Background & aims: Reported global incidence and prevalence values for achalasia vary widely, from 0.03 to 1.63/100,000 persons per year and from 1.8 to 12.6/100,000 persons per year, respectively. This study aimed to reconcile these low values with findings from a major referral center, in central Chicago (which began using high-resolution manome...

Background: Criteria for transient lower esophageal sphincter relaxations (TLESRs) are well-defined for Dentsleeve manometry. As high-resolution manometry (HRM) is now the gold standard to assess esophageal motility, our aim was to propose a consensus definition of TLESRs using HRM. Methods: Postprandial esophageal HRM combined with impedance wa...

Background: Peroral endoscopic myotomy (POEM) is a novel surgical option for the treatment of achalasia. Most centers perform a routine esophagram on postoperative day (POD) #1 to rule esophageal perforation and leaks. In this study, we sought to determine the clinical utility of routine contrast studies post-POEM. Methods: POEM was performed us...

Background: Esophageal dysphagia is common in gastroenterology practice and has multiple etiologies. A complication for some patients with dysphagia is food impaction. A valid and reliable questionnaire to rapidly evaluate esophageal dysphagia and impaction symptoms can aid the gastroenterologist in gathering information to inform treatment approa...

Chronic kidney disease has joined the growing list (pneumonia, myocardial infarction, hip fracture, Clostridium difficile infections, acute interstitial nephritis, hypomagnesaemia) of putative risks associated with chronic PPI use based on results from an observational epidemiological study. However, the low hazard ratio (<1.5) makes it doubtful th...

Limsrivilai et al. report on a randomized control trial (RCT) testing the efficacy of imipramine for treating esophageal hypersensitivity and functional heartburn, the first RCT to test this therapy in this indication. Among 43 functional heartburn and esophageal hypersensitivity patients randomized to treatment with 25 mg qhs imipramine and 40 ran...

Background: We aimed to define normative values for novel pressure topography metrics for high-resolution pharyngeal-esophageal manofluorography. The effects of age, gender, and bolus properties were examined. Methods: Concurrent high-resolution manometry (HRM) and videofluoroscopy data were collected from 22 younger (aged 21-40) and 22 older (a...

Even as the preferred treatment of achalasia migrates towards per-oral endoscopic myotomy (POEM), the relative merits of pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) continue to be argued. In this issue of Gut , the long-term results of the European achalasia trial comparing 201 patients randomised to PD or LHM are presented,1 repo...

A prerequisite for the development of Barrett's esophagus (BE) is gastro-esophageal reflux disease (GERD). Previous studies have noted that patients with Barrett's esophagus have a substantial amount of reflux, comparable to patients with erosive esophagitis. The pathologic effect of GERD on the esophagus is determined by both the frequency of refl...

Background: Achalasia has three distinct manometric phenotypes. This study aimed to determine if there were corresponding histopathologic patterns. Methods: We retrospectively examined surgical muscularis propria biopsies obtained from 46 patients during laparoscopic esophagomyotomy. Pre-operative (conventional) manometry tracings were reviewed...

Esophageal motility disorders can be categorized based on anatomical localization, neurologic control and muscle type involved. The oropharynx and proximal esophagus are composed of striated muscle and are under central nervous system control. In contrast, the distal esophagus is predominantly composed of smooth muscle and is controlled by the ente...

Genesis of persistent gastro-esophageal reflux symptoms despite proton pump inhibitor (PPI) therapy is not fully understood. We aimed at determining reflux patterns on 24-h pH-impedance monitoring performed on PPI and correlating impedance patterns and symptom occurrence in PPI non-responders. Seventy-eight PPI non-responder patients underwent 24-h...

With the widespread use of proton pump inhibitors (PPIs), the frontier of treating reflux disease has shifted from refractory esophagitis to PPI-refractory symptoms. However, symptoms are inherently less specific than mucosal disease and, as noted by Herregods et al. in their contribution appearing in this issue of Neurogastroenterology and Motilit...

Gastroesophageal reflux disease (GERD) encompasses an array of disorders unified by the reflux of gastric contents. Because there are many potential disease manifestations, esophageal and extraesophageal, there is no single biomarker of the entire disease spectrum; a set of GERD biomarkers that each quantifies specific aspects of GERD-related patho...

The functional lumen imaging probe (FLIP) could improve characterization of achalasia subtypes by detecting non-occlusive esophageal contractions not observed with standard manometry. We aimed to evaluate for esophageal contractions during volumetric distention in patients with achalasia using FLIP topography. Fifty one treatment-naïve patients wit...

The interactions among pepsin, acid, and mucosal injury have been a subject of interest since studies in the 1960s implicated pepsin as a major determinant of reflux injury at low pH.¹ In its enzymatically active form, pepsin is the primary proteolytic enzyme of the digestive tract and key to the pathogenesis of “peptic” esophagitis in gastroesopha...

Objectives: In mild gastroesophageal reflux disease, which accounts for the great majority of cases, the major burden of reflux occurs during daytime hours, after food intake. The aim of these analyses was to evaluate intragastric pH control during the typical 14-hour daytime awake period by proton-pump inhibitors (PPIs) given at over-the-counter...

Based on a fully-coupled active musculo-mechanical model for esophageal transport, we aimed to find the roles of circular muscle (CM) contraction and longitudinal muscle (LM) shortening in esophageal transport, and the influence of their coordination. Two groups of studies were conducted using a computational model. In the first group, bolus transp...

During peroral esophageal myotomy (POEM) for the treatment of achalasia, the optimal distal gastric myotomy length is unknown. In this study, we used a functional lumen imaging probe (FLIP) to intraoperatively measure the effect of variable distal myotomy lengths on esophagogastric junction (EGJ) distensibility. EGJ distensibility index (DI) (minim...

We assessed whether a high-resolution impedance manometry (HRIM) metric, bolus flow time (BFT) across the esophagogastric junction (EGJ), was abnormal in achalasia patients subtyped by the Chicago Classification and compared BFT to other HRM metrics. HRIM studies were performed in 60 achalasia patients (14 type I, 36 type II and 10 type III) and 15...

The functional lumen imaging probe (FLIP) measures luminal cross-sectional area and pressure during volumetric distension. By applying novel customized software to produce FLIP topography plots, organized esophageal contractility can be visualized and analyzed. We aimed to describe the stimulus thresholds and contractile characteristics for distens...

doi: 10.1038/ajg.2015.55 http://www.nature.com/ajg/journal/vaop/ncurrent/abs/ajg201555a.html OBJECTIVES: Barrett’s esophagus (BE) is a common premalignant lesion for which surveillance is recommended. This strategy is limited by considerable variations in clinical practice. We conducted an international, multidisciplinary, systematic search and ev...

Objectives: Enhanced characterization of esophageal peristaltic and sphincter function provided by esophageal pressure topography (EPT) offers a potential diagnostic advantage over conventional line tracings (CLT). However, high-resolution manometry (HRM) and EPT require increased equipment costs over conventional systems and evidence demonstratin...

Proton pump inhibitors (PPIs) have a well-established safety profile. However, concerns have been raised about a potential relationship between PPI-induced hypergastrinaemia and the development of enterochromaffin-like (ECL) cell hyperplasia, neuroendocrine tumours and gastric cancer during long-term therapy. To review the effects of long-term PPI...

High-resolution manometry (HRM) expands recognition of minor esophageal motor abnormalities, but the clinical significance of these is unclear. We aimed to determine the outcomes of minor esophageal motor abnormalities. We reviewed HRM tracings from individuals who underwent esophageal manometry at Northwestern Memorial Hospital from July 2004 thro...

Esophageal transport is a physiological process that mechanically transports an ingested food bolus from the pharynx to the stomach via the esophagus, a multi-layered muscular tube. This process involves interactions between the bolus, the esophagus, and the neurally coordinated activation of the esophageal muscles. In this work, we use an immersed...

Esophageal high-resolution manometry (HRM) has rapidly gained much popularity worldwide. The Chicago Classification for esophageal motility disorders is based on a set of normative values for key metrics that was obtained using one of the commercially available HRM systems. Thus, it is of great importance to evaluate whether these normative values...

The Chicago Classification (CC) of esophageal motility disorders, utilizing an algorithmic scheme to analyze clinical high-resolution manometry (HRM) studies, has gained acceptance worldwide. This 2014 update, CC v3.0, developed by the International HRM Working Group, incorporated the extensive clinical experience and interval publications since th...

& Aims: Gastroesophageal reflux disease (GERD) is a common and costly disorder. Symptoms attributed to GERD have a wide spectrum of presentations and complications that have led to complex diagnostic and management algorithms. As such, there is considerable variation in clinical approaches to GERD. In contrast to multiple published guidelines for t...

Barrett's oesophagus, with the potential to develop into oesophageal adenocarcinoma (OAC), is a major complication of gastrooesophageal reflux disease (GORD). However, about 50% of patients developing OAC had no known GORD beforehand. Hence, while GORD symptoms, oesophagitis, and Barrett's have a number of common determinants (oesophagogastric junc...

#### Summary points Hiatus hernia is a condition involving herniation of the contents of the abdominal cavity, most commonly the stomach, through the diaphragm into the mediastinum. In the United States, hiatus hernia was listed as a primary or secondary cause of hospital admissions in 142 of 10 000 inpatients between 2003 and 2006.1 However, the...

Background & aims: Transoral esophagogastric fundoplication (TF) can decrease or eliminate features of gastroesophageal reflux disease (GERD) in some patients whose symptoms persist despite proton pump inhibitor (PPI) therapy. We performed a prospective, sham-controlled trial to determine if TF reduced troublesome regurgitation to a greater extent...

The Chicago Classification defines esophageal motility disorders in high resolution manometry. This is based on individual scoring of 10 swallows performed in supine position. Disorders of esophago-gastric junction (EGJ) outflow obstruction are defined by a median integrated relaxation pressure above the limit of normal and divided into 3 achalasia...

Bronchopulmonary C-fibers and a subset of mechanically sensitive, acid-sensitive myelinated sensory nerves play essential roles in regulating cough. These vagal sensory nerves terminate primarily in the larynx, trachea, carina and large intrapulmonary bronchi. Other bronchopulmonary sensory nerves, sensory nerves innervating other viscera as well a...

Lower esophageal sphincter vector volume (V-V) was developed in the late 1980s by Bombeck, as a quantification of sphincter integrity used to select reflux patients with a defective valve who may benefit from surgery. Its calculation required motorized pull-through of an 8-lumen water perfused manometry catheter with subsequent computerized reconst...

Background Esophageal motor disorders are a heterogeneous group of conditions identified by esophageal manometry that lead to esophageal dysfunction. The aim of this study was to assess the clinical utility of endoscopic ultrasound (EUS) in the further evaluation of patients with esophageal motor disorders categorized using the updated Chicago Clas...

This overview will demonstrate that cough is a common and potentially expensive health care problem. Improvement in the quality of care of those with cough has been the focus of study for a variety of disciplines in medicine. The purpose of the Cough Guideline and Expert Panel is to synthesize current knowledge in a form that will aide clinical dec...

Background: The functional lumen imaging probe (FLIP) is a novel diagnostic tool that can be used to measure esophagogastric junction (EGJ) distensibility. In this study, we performed intraoperative FLIP measurements during laparoscopic Heller myotomy (LHM) and peroral esophageal myotomy (POEM) for treatment of achalasia and evaluated the relation...

Background Recent studies have shown that Gaviscon Double Action Liquid (a combination alginate-antacid) administered post-prandially co-localises with the acid pocket, the ‘reservoir’ for post-prandial acid reflux.AimThis study compared the effectiveness of Gaviscon Double Action Liquid to an equivalent strength antacid without alginate in control...

Background Little is known regarding patient characteristics that influence the speed of reflux oesophagitis (RO) healing.AimTo investigate patient characteristics that may influence RO healing rates.MethodsA post hoc analysis of clinical trial data for potent acid suppression treatment of RO (esomeprazole or AZD0865) was conducted. Group A underwe...

Background and Aims: We aimed to model esophageal bolus transit based on esophageal pressure topography (EPT) landmarks, concurrent intrabolus pressure (IBP) and esophageal diameter as defined with fluoroscopy. Methods: 10 healthy subjects were studied with high-resolution impedance manometry (HRIM) and videofluoroscopy. Data from four 5-ml barium...

Background Peroral esophageal myotomy (POEM) is a new endoscopic operation for the treatment of achalasia. Here, we report 1-year physiologic and symptomatic outcomes following the procedure. Methods POEM patients from a single-institution series who were more than 1 year removed from surgery were studied. Eckardt and GerdQ scores were obtained...

Background: For laparoscopic Heller myotomy (LHM), the optimal myotomy length proximal to the esophagogastric junction (EGJ) is unknown. In this study, we used a functional lumen imaging probe (FLIP) to measure EGJ distensibility changes resulting from variable proximal myotomy lengths during LHM and peroral esophageal myotomy (POEM). Methods: D...

Background: Upper gastrointestinal (GI) complaints are common in ambulatory GI clinics. While PPIs have successfully treated straightforward cases of GERD, many esophageal patients, particularly those with functional conditions, present with refractory symptoms. Behavioral interventions aimed at treating the underlying cognitive and affective proce...

Upper gastrointestinal complaints are common among patients in a gastrointestinal clinic. Outside of typical gastroesophageal reflux disease symptoms that are treated with medication, the symptom presentations of esophageal patients, particularly those with functional conditions, are often difficult to treat and account for high health-care utiliza...