Esophageal shortening after rapid drink test during esophageal high-resolution manometry: A relevant finding?

Abstract

Background: Esophageal shortening (ES) might be observed during high-resolution manometry (HRM), in particular after the rapid drink test (RDT). We aimed to assess its diagnostic value in patients referred for HRM.

Methods: HRM of patients without previous esophagogastric surgery or endoscopic treatment was retrospectively reviewed using the Chicago Classification v3.0. ES and pan-esophageal pressurization were analyzed during the RDT (200-ml free drinking in a sitting position).

Results: A total of 2141 cases (1291 females, mean age 54 years) were reviewed. During the RDT, ES occurred in 4% and pan-esophageal pressurization in 14% of patients. ES was almost exclusively encountered in patients with impaired esophagogastric junction relaxation or major disorders of peristalsis. Among 31 patients with ES and no definite diagnosis of achalasia, 19 had follow-up and 13 (68%) changed diagnostic category: two adenocarcinoma of the cardia, and 11 cases of atypical achalasia. The positive predictive value of ES for a significant esophageal disorder was 95%.

Conclusion: ES is rarely observed during the RDT. When present, it is associated with major motility disorders, especially achalasia. When the diagnostic criteria for achalasia are not fulfilled, further complementary examinations should be performed to rule out incomplete forms of achalasia or an infiltrative process of the cardia.

Keywords: Achalasia; dysphagia; esophageal motility disorder; human; predictive positive value.

Figure 1.

Esophageal shortening and pan-esophageal pressurization during the rapid drink test (RDT). The pink boxes above the pressure topography plots indicate the period with repetitive swallows during RDT. (a) Esophageal shortening is defined as an elevation of the lower esophageal sphincter (LES) greater than 1 cm (7.5 cm on this example; the dashed lines indicate the lower border of the LES). (b) Pan-esophageal pressurization is defined as a homogeneous pressurization > 30 mmHg between the upper esophageal sphincter (UES) and the LES (indicated with vertical white arrows).