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OWE-031 Oesophageal aperistalsis is under investigated in those without achalasia or reflux

Authors:

Abstract

Introduction Oesophageal aperistalsis (OA) is the absence of oesophageal motility with water swallows at high-resolution manometry (HRM). The main causes are achalasia and reflux although in many patients no cause is found, therefore we aimed to investigate the number of patients with an identifiable cause of OA and the number of patients in whom the most common aetiologies have been determined. There is no consensus for the investigation of OA without achalasia; this will depend on how common the underlying aetiology is. Methods We examined the reports of patients who had HRM at Guy’s and St. Thomas’ NHS Trust from January 2008 to July 2017. 492 patients had OA as per the Chicago Classification 2014; achalasia was defined as an integrated relaxation pressure (IRP) of >15 mmHg or IRP 12–15 mmHg and a barium swallow or other imaging or a previous myotomy for achalasia was identified. For those without achalasia, Gastroesophageal reflux disease (GORD) was defined according to any pH study off PPI. Patients without GORD or achalasia were classified as non-achalasia, non-reflux aperistalsis (NANRA). Non-achalasia patients without a pH study were excluded (n≥35). The electronic patient record of NANRA patients was consulted to look for evidence of autoimmune disorders (AD), eosinophilic oesophagitis (EoE) or previous oesophageal surgery. Results Among 457 included patients we defined three categories: 183 (40%) had achalasia, 185 (41%) had GORD and 89 (19%) had NANRA.Of the 89 NANRA patients, 29% had an AD including Systemic Lupus Erythematosus, Scleroderma, Sjögren syndrome and Antisynthetase syndrome (n≥25, M:F 3:7, average age ≥48). One had Myotonic Dystrophy (n≥1); 11% (n≥10) had hypersensitive oesophagus; 6% (n≥5) had surgery for atresia, oesophageal spasm, or gastric cancer; 2% (n≥2) had EoE and in 2% (n≥2) of patients AD screen and EoE screen were normal. The remaining 50% of NANRA patients (n≥44) had an unknown cause but incomplete investigations (no screen for AD: 97.7%; no biopsy: 67.4%). Conclusions 1.The principal cause of OA is achalasia; it shouldn’t be dismissed as a cause even if the IRP is <15 mmHg as 6.5% (n≥12) of patients with achalasia and OA had IRP <15 mmHg but typical radiological findings.2.GORD is present in 41% of patients but it is unclear whether it is a cause or effect of OA, therefore the finding of GORD should not stop further investigation. 3.Patients with OA are under investigated for AD and EoE. 50% of patients with NANRA had incomplete investigations potentially losing the opportunity to identify other aetiologies. It is unclear whether NANRA patients should be routinely tested for AD or for EoE, or whether this should be done only in selected cases.
44.4% in 15 Hz group (p0.480). One patient had numbness/
tingling in the right arm in 5 Hz group.
Conclusions In this interim analysis, repetitive translumbar and
transsacral magnetic stimulation appears safe, and at 1 Hz fre-
quency showed significant superiority when compared to
higher frequencies for the treatment of FI. This non-invasive
neuromodulation modality offers promise as a novel treatment
approach for FI.
Abstract OWE-030 Table 1 Summary of results
1 Hz 5 Hz 15 Hz
Baseline Post-
Treat
Baseline Post-
Treat
Baseline Post-
Treat
FI episodes/Wk 7.1±2.7 2.0±1.3* 10.6
±4.5
9.1±3.7 5.0±2.5 2.3±0.8*
Responder rate
(%)
88.9%]25% 44.4%
FISI score d(%) 34.6±18.4 12.0±4.9 17.6±16.1
Considerable or
Complete relief
66.7% 37.5% 44.4%
Mild or
Unchanged
33.3% 62.5% 44.4%
Worse 0 0 11.1%
Bold = *p<0.05 vs baseline; ]vs 5Hz
OWE-031 OESOPHAGEAL APERISTALSIS IS UNDER
INVESTIGATED IN THOSE WITHOUT ACHALASIA OR
REFLUX
1
Mr Pierfrancesco Visaggi*,
2
Hajir Ibraheim,
2
Terry Wong,
2
Jafar Jafari,
2
Jason Dunn,
2
Sebastian Zeki.
1
University of Pisa, Pisa, Italy;
2
Dept Gastroenterology, St ThomasHospital,
London, UK
10.1136/gutjnl-2018-BSGAbstracts.419
Introduction Oesophageal aperistalsis (OA) is the absence of
oesophageal motility with water swallows at high-resolution
manometry (HRM). The main causes are achalasia and reflux
although in many patients no cause is found, therefore we
aimed to investigate the number of patients with an identifi-
able cause of OA and the number of patients in whom the
most common aetiologies have been determined. There is no
consensus for the investigation of OA without achalasia; this
will depend on how common the underlying aetiology is.
Methods We examined the reports of patients who had HRM at
Guys and St. ThomasNHS Trust from January 2008 to July
2017. 492 patients had OA as per the Chicago Classification
2014; achalasia was defined as an integrated relaxation pressure
(IRP) of >15 mmHg or IRP 1215 mmHg and a barium swallow
or other imaging or a previous myotomy for achalasia was identi-
fied. For those without achalasia, Gastroesophageal reflux disease
(GORD) was defined according to any pH study off PPI. Patients
without GORD or achalasia were classified as non-achalasia, non-
reflux aperistalsis (NANRA). Non-achalasia patients without a pH
study were excluded (n35). The electronic patient record of
NANRA patients was consulted to look for evidence of autoim-
mune disorders (AD), eosinophilic oesophagitis (EoE) or previous
oesophageal surgery.
Results Among 457 included patients we defined three catego-
ries: 183 (40%) had achalasia, 185 (41%) had GORD and 89
(19%) had NANRA.
Of the 89 NANRA patients, 29% had an AD including
Systemic Lupus Erythematosus, Scleroderma, Sjögren syndrome
and Antisynthetase syndrome (n25, M:F 3:7, average
age 48). One had Myotonic Dystrophy (n1); 11% (n10)
had hypersensitive oesophagus; 6% (n5) had surgery for
atresia, oesophageal spasm, or gastric cancer; 2% (n2) had
EoE and in 2% (n2) of patients AD screen and EoE screen
were normal. The remaining 50% of NANRA patients (n44)
had an unknown cause but incomplete investigations (no
screen for AD: 97.7%; no biopsy: 67.4%).
Conclusions 1.The principal cause of OA is achalasia; it
shouldnt be dismissed as a cause even if the IRP
is <15 mmHg as 6.5% (n12) of patients with achalasia and
OA had IRP <15 mmHg but typical radiological findings.
2.GORD is present in 41% of patients but it is unclear
whether it is a cause or effect of OA, therefore the finding of
GORD should not stop further investigation.
3.Patients with OA are under investigated for AD and EoE.
50% of patients with NANRA had incomplete investigations
potentially losing the opportunity to identify other aetiologies.
It is unclear whether NANRA patients should be routinely
tested for AD or for EoE, or whether this should be done
only in selected cases.
OWE-032 A RANDOMISED PLACEBO-CONTROLLED TRIAL OF A
MULTI-STRAIN PROBIOTIC FORMULATION. (BIO-KULT
®
)
IN THE MANAGEMENT OF IBS-D
Shamsuddin Ishaque*, Sheikh Mohammed Khosruzzaman, Dewan Saifuddin Ahmed,
Mukesh Prasad Sah, Malwina Naghibi*. Bangabandhu Sheikh Mujib Medical University
(BSMMU), Dhaka, Bangladesh
10.1136/gutjnl-2018-BSGAbstracts.420
Introduction Increasing evidence supports the viewpoint that
alterations in the diversity and function of gastrointestinal bac-
teria contributes to IBS, and that increasing the mass of bene-
ficial species, by consuming probiotics, may lower pathogenic
bacteria numbers and help alleviate symptoms.
Methods In this double-blind trial, a total of 360 adult
patients with moderate-to-severe symptomatic diarrhoeapredo-
minant IBS (IBS-D) were randomised to receive either treat-
ment with the multi-strain probiotic Bio-Kult (14 different
bacterial strains) or placebo for 16 weeks. The primary out-
come measure was change in abdominal pain. The secondary
outcomes included frequency of bowel motions, overall change
in IBS-severity scoring system (IBS-SSS) and IBS specific qual-
ity of life (IBS-QoL).
Results In comparison to placebo, treatment with probiotics
significantly alleviated the severity of abdominal pain in
patients with IBS-D: 69% reduction for probiotic versus 47%
for placebo (p<0.001), equating to a 145 point reduction on
the IBS-SSS. The level of patients rating their symptoms as
moderate-to-severe was reduced from 100% at baseline to
14% in the multi-strain probiotic group by follow-up (month
5) versus 48% for placebo (p<0.001). In addition, the num-
ber of bowel motions per day from month 2 onwards was
significantly reduced in the probiotic group compared with
the placebo group (p<0.05). In addition to relieving symp-
toms, the probiotic markedly improved all dimensions of qual-
ity of life in the 34-item IBS-QoL questionnaire. No serious
adverse events were reported.
Conclusions The multi-strain probiotic was associated with signifi-
cant improvement in symptoms in IBS-D patients, and was well-
Abstracts
A210 Gut 2018;67(Suppl 1):A1A304
on February 13, 2021 by guest. Protected by copyright.http://gut.bmj.com/Gut: first published as 10.1136/gutjnl-2018-BSGAbstracts.419 on 8 June 2018. Downloaded from
... Similarly, Savarino et al. [59] found that, in a cohort of 35 EoE patients, 17% had achalasia or obstructive motility disorders, 26% showed hypomotility disorders including IEM, fragmented or absent peristalsis, whereas 57% had normal peristalsis. Another study by Visaggi et al. [60] found that EoE could account for at least 2% of the diagnoses of absent peristalsis in a large cohort of patients who had undergone HRM at a tertiary referral center in the UK. In 2021, a prospective study conducted in a tertiary referral center in Italy found that, of 21 EoE patients undergoing HRM, 52% had abnormal motility, including achalasia, EGJ-OO, hypercontractile esophagus, and DES [61]. ...
... Table 1 reports a summary of the studies assessing esophageal motility in EoE. [36] Retrospective CM 10 NSMD Hempel [37] Retrospective CM Tertiary contractions at baseline CM and resolution of dysmotility following corticosteroid treatment Cheung [41] Retrospective CM 11 normal peristalsis Lucendo [38] Retrospective CM 1 absent peristalsis Lucendo [39] Retrospective CM 6 NSMD 3 hypercontractility 2 normal motility 1 primary simultaneous waves Bassett [42] Prospective CM 23 normal peristalsis 5 NSMD 2 high-amplitude peristaltic waves Nurko [60] Retrospective CM 7 NSMD 10 normal peristalsis Moawad [40] Retrospective CM 47 normal peristalsis 25 IEM 3 NE Monnerat [43] Prospective CM 15 normal peristalsis 3 IEM 2 LES dysfunction Martin [44] Prospective HRM (CC V1.0) 6 peristaltic dysfunction 5 normal peristalsis 10 PEP Roman [46] Retrospective HRM (CC V1.0) 30 normal peristalsis 8 weak peristalsis 5 frequent failed peristalsis 2 rapid contractions 1 absent peristalsis 1 hypertensive peristalsis 1 functional EGJ obstruction Savarino [48] Retrospective HRM (CC V1.0) 1 achalasia Clayton [50] Retrospective HRM (CC V2.0) 10 normal peristalsis 1 jackhammer esophagus 2 weak peristalsis 1 EGJ-OO 1 hypertensive LES Nennstiel [47] Prospective HRM (CC V1.0) 12 normal peristalsis 7 early PEP 1 CDP Savarino [52] Retrospective HRM (CC V3.0) 20 normal peristalsis 4 fragmented peristalsis 3 IEM 3 EGJ-OO 2 absent peristalsis 2 DES 1 achalasia ...
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Eosinophilic esophagitis (EoE) represents a growing cause of chronic esophageal morbidity whose incidence and prevalence are increasing rapidly. The disease is characterized by eosinophilic infiltrates of the esophagus and organ dysfunction. Typical symptoms include dysphagia, chest pain, and bolus impaction, which are associated to mechanical obstructions in most patients. However, up to one in three EoE patients has no visible obstruction, suggesting that a motor disorder of the esophagus may underlie symptoms. Although potentially relevant for treatment refractoriness and symptomatic burden, esophageal dysmotility is often neglected when assessing EoE patients. The first systematic review investigating esophageal motility patterns in patients with EoE was published only recently. Accordingly, we reviewed the pathogenesis, assessment tools, manometric characteristics, and clinical implications of dysmotility in patients with EoE to highlight its clinical relevance. In summary, eosinophils can influence the amplitude of esophageal contractions via different mechanisms. The prevalence of dysmotility may increase with disease duration, possibly representing a late feature of EoE. Patients with EoE may display a wide range of motility disorders and possible disease-specific manometric pressurization patterns may be useful for raising a clinical suspicion. Intermittent dysmotility events have been found to correlate with symptoms on prolonged esophageal manometry, although high-resolution manometry studies have reported inconsistent results, possibly due to the suboptimal sensitivity of current manometry protocols. Motor abnormalities may recover following EoE treatment in a subset of patients, but invasive management of the motor disorder is required in some instances. In conclusion, esophageal motor abnormalities may have a role in eliciting symptoms, raising clinical suspicion, and influencing treatment outcome in EoE. The assessment of esophageal motility appears valuable in the EoE setting.
... In 2018, a ten-year retrospective study by Visaggi et al. [47] found that 2% of patients with an identifiable cause of absent peristalsis may have EoE; however, 50% of patients without a clear cause of absent peristalsis had not undergone esophageal biopsy to rule out EoE, possibly losing the opportunity to identify the disease. In the same year, Hosaka et al. [48] described 18 patients with EoE who had undergone HRM: 3 had normal peristalsis, 7 achalasia, 3 IEM, 2 EGJOO or JE, and 1 DES. ...
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Background: Eosinophilic esophagitis (EoE) is a chronic disorder of the esophagus characterized by an eosinophil-predominant inflammation and symptoms of esophageal dysfunction. Eosinophils can influence esophageal motility, leading to dysphagia worsening. The spectrum of esophageal motility in EoE is uncertain. Aim: We performed a systematic review to investigate esophageal motility in EoE. Methods: MEDLINE, EMBASE and EMBASE Classic were searched from inception to 16th November 2021. Studies reporting esophageal motility findings in EoE patients by means of conventional, prolonged, and/or high-resolution esophageal manometry were eligible. Results: Studies on esophageal conventional and high-resolution manometry (HRM) found that all types of manometric motor patterns can be found in patients with EoE and investigations on 24-hour prolonged manometry demonstrated an association between symptoms and intermittent dysmotility events, which can be missed during standard manometric analysis. Panesophageal pressurizations are the most common HRM finding and may help in formulating a clinical suspicion. Some motility abnormalities may reverse after medical treatment, while other major motility disorders like achalasia require invasive management for symptoms control. HRM metrics have demonstrated to correlate with inflammatory and fibrostenotic endoscopic features of EoE. Conclusion: Esophageal motor abnormalities are common in patients with EoE and may contribute to symptoms. The resolution of dysmotility after medical treatment corroborates that eosinophils influence esophageal motility.
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