Impact of symptom burden and health-related quality of life (HRQOL) on esophageal motor diagnoses

Abstract

Background: High-resolution manometry (HRM) categorizes esophageal motor processes into specific Chicago Classification (CC) diagnoses, but the clinical impact of these motor diagnoses on symptom burden remain unclear.

Methods: Two hundred and eleven subjects (56.8±1.0 years, 66.8% F) completed symptom questionnaires (GERDQ, Mayo dysphagia questionnaire [MDQ], visceral sensitivity index, short-form 36, dominant symptom index, and global symptom severity [GSS] on a 100-mm visual analog scale) prior to HRM. Subjects were stratified according to CC v3.0 and by dominant presenting symptom; contraction wave abnormalities (CWA) were evaluated within "normal" CC. Symptom burden, impact of diagnoses, and HRQOL were compared within and between cohorts.

Key results: Major motor disorders had highest global symptom burden (P=.02), "normal" had lowest (P<.01). Dysphagia (MDQ) was highest with esophageal outflow obstruction (P=.02), but reflux symptoms (GERDQ) were similar in CC cohorts (P=ns). Absent contractility aligned best with minor motor disorders. Consequently, pathophysiologic categorization into outflow obstruction, hypermotility, and hypomotility resulted in a gradient of decreasing dysphagia and increasing reflux burden (P<.05 across groups); GSS (P=.05) was highest with hypomotility and lowest with "normal" (P=.002). Within the "normal" cohort, 33.3% had CWA; this subgroup had symptom burden similar to hypermotility. Upon stratification by symptoms, symptom burden (GSS, MDQ, HRQOL) was most profound with dysphagia.

Conclusions and inferences: Chicago Classification v3.0 diagnoses identify subjects with highest symptom burden, but pathophysiologic categorization may allow better stratification by symptom type and burden. Contraction wave abnormalities are clinically relevant and different from true normal motor function. Transit symptoms have highest yield for a motor diagnosis.

Keywords: Chicago Classification; dysphagia; high-resolution manometry; symptom burden.

Figure 1

Dysphagia severity (Mayo Dysphagia Questionnaire) and GERDQ impact score across motor groups. A. Dysphagia severity and GERDQ impact scores follow gradients in opposite directions when absent contractility is extracted out of the major motor disorders category. B. Similar gradients are maintained when motor disorders are grouped by pathophysiologic mechanisms to outflow obstruction, hypermotility disorders and hypomotility disorders, where absent contractility is included with hypomotility disorders.

Figure 1

Dysphagia severity (Mayo Dysphagia Questionnaire) and GERDQ impact score across motor groups. A. Dysphagia severity and GERDQ impact scores follow gradients in opposite directions when absent contractility is extracted out of the major motor disorders category. B. Similar gradients are maintained when motor disorders are grouped by pathophysiologic mechanisms to outflow obstruction, hypermotility disorders and hypomotility disorders, where absent contractility is included with hypomotility disorders.

Figure 2

Proportions of motor diagnosis according to presenting symptom. A. Chicago Classification 3.0 diagnosis groups. The ‘normal’ group is further categorized into those with contraction wave abnormalities (CWA) and true normal. B. Pathophysiologic groups. The hypermotility group includes diffuse esophageal spasm and hypercontractile disorder (jackhammer esophagus), and the hypomotility group includes ineffective esophageal motility, fragmented peristalsis and absent contractility.

Figure 2

Proportions of motor diagnosis according to presenting symptom. A. Chicago Classification 3.0 diagnosis groups. The ‘normal’ group is further categorized into those with contraction wave abnormalities (CWA) and true normal. B. Pathophysiologic groups. The hypermotility group includes diffuse esophageal spasm and hypercontractile disorder (jackhammer esophagus), and the hypomotility group includes ineffective esophageal motility, fragmented peristalsis and absent contractility.