Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Mar;33(3):e14000.
doi: 10.1111/nmo.14000. Epub 2020 Oct 11.

Multiple rapid swallows and rapid drink challenge in patients with esophagogastric junction outflow obstruction on high-resolution manometry

Amanda J Krause  1 , Hui Su  2 , Joseph R Triggs  1   3 , Claire Beveridge  1   3 , Alexandra J Baumann  1 , Erica Donnan  1 , John E Pandolfino  1 , Dustin A Carlson  1
Affiliations

Multiple rapid swallows and rapid drink challenge in patients with esophagogastric junction outflow obstruction on high-resolution manometry

Amanda J Krause et al. Neurogastroenterol Motil. 2021 Mar.

Abstract

Background: Esophagogastric junction outflow obstruction (EGJOO) as defined by Chicago Classification of esophageal motility disorders (CCv3.0) encompasses a broad range of diagnoses, thus posing clinical challenges. Our aims were to evaluate multiple rapid swallow (MRS) and rapid drink challenge (RDC) during high-resolution manometry (HRM) to aid identifying clinically relevant EGJOO.

Methods: Patients with a HRM diagnosis of EGJOO based on CCv3.0 that also completed MRS and RDC during HRM and barium esophagram were retrospectively identified. Radiographic EGJOO (RAD-EGJOO) was defined by either liquid barium retention or delayed passage of a barium tablet on barium esophagram. Thirty healthy asymptomatic controls that completed HRM were also included. MRS involved drinking 2 mL for 5 successive swallows. RDC involved rapid drinking of 200 mL liquid. Integrated relaxation pressure (IRP) and presence of panesophageal pressurization (PEP) during MRS and RDC were assessed.

Key results: One hundred one patients, mean (SD) age 56 (16) years, were included; 32% had RAD-EGJOO, 68% did not. RAD-EGJOO patients more frequently had elevated (>12 mmHg) upright IRP (100%), MRS-IRP (56%), RDC-IRP (53%), and PEP during RDC (66%) than both controls [17%; 0%; 7%; 3%] and patients without RAD-EGJOO [83%; 35%; 39%; 41%] Having IRP >12 mmHg during both MRS and RDC was twice as likely to be associated with RAD-EGJOO (19%) than those without RAD-EGJOO (9%) among patients with upright IRP >12 mmHg.

Conclusions and inferences: Adjunctive HRM maneuvers MRS and RDC appear to help identify clinically significant EGJOO. While future outcome studies are needed, comprehensive multimodal evaluation helps clarify relevance of EGJOO on HRM.

Keywords: achalasia; diagnostic tests; dysphagia; endoscopy; motility.

PubMed Disclaimer

Figures

Figure 1:
Figure 1:. Multiple rapid swallow (MRS) and rapid drink challenge (RDC) Interpretation.
MRS (A) and RDC (B) from a control and MRS (C) and RDC (D) from a patient are displayed. Integrated relaxation pressure (IRP) values were 5 mmHg in A, 1 mmHg in B, 31 mmHg in C, and 20 mmHg in D. Panesophageal pressurization (PEP) was observed in the patient (C and D), but not the control. Figure used with permission from the Esophageal Center at Northwestern.
Figure 2:
Figure 2:. Receiver operating characteristic (ROC) curves to predict radiographic esophagogastric junction outflow obstruction (RAD-EGJOO).
A. Prediction of RAD-EGJOO on comparison with controls. B. Prediction of RAD-EGJOO on comparison with patients without RAD-EGJOO. MRS – multiple rapid swallows. RDC – rapid drink challenge. IRP – integrated relaxation pressure. AUC – area under the curve 1Median value of supine or upright swallows, respectively.
Figure 3:
Figure 3:. Application of decision tree to assess for radiographic esophagogastric junction outflow obstruction (RAD-EGJOO).
Application of a the stepwise approach to apply 1) Upright IRP, then 2) MRS-IRP and RDC-IRP, demonstrated the greatest proportion of esophagram/HRM positive/positive (red-shading) were identified with upright, MRS, and RDC IRPs > 12mmHg, and greatest proportion of negative/negative (blue shading) had upright, MRS, RDC IRP <12mmHg. Persistent overlap of outcome groups is still notable however. MRS – multiple rapid swallows. RDC – rapid drink challenge. IRP – integrated relaxation pressure. Figure used with permission from the Esophageal Center at Northwestern.
Figure 4.
Figure 4.. Examples of patients with EGJ outflow obstruction on high-resolution manometry.
A. After presenting with chest pain and having a normal endoscopy, HRM demonstrated EGJOO with median supine integrated relaxation pressure (IRP) of 21 mmHg. IRP remained >12mmHg in the upright position, but normalized with both multiple rapid swallows (MRS) and rapid drink challenge (RDC). Barium esophagram was normal. B. After presenting with dysphagia and having a normal endoscopy, HRM demonstrated EGJOO with median supine IRP 18 mmHg. IRP elevation persisted with upright swallows, MRS, and RDC. Panesophageal pressurization (PEP) was also observed with both MRS and RDC. Timed-barium esophagram demonstrated barium retention. Figure used with permission from the Esophageal Center at Northwestern.
See this image and copyright information in PMC

References

    1. Pandolfino JE, Kahrilas PJ. American Gastroenterological Association medical position statement: Clinical use of esophageal manometry. Gastroenterology. 2005;128(1):207–208. - PubMed
    1. Pandolfino JE, Ghosh SK, Rice J, Clarke JO, Kwiatek MA, Kahrilas PJ. Classifying esophageal motility by pressure topography characteristics: a study of 400 patients and 75 controls. Am J Gastroenterol. 2008;103(1):27–37. - PubMed
    1. Kahrilas PJ, Bredenoord AJ, Fox M, et al. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil. 2015;27(2):160–174. - PMC - PubMed
    1. Scherer JR, Kwiatek MA, Soper NJ, Pandolfino JE, Kahrilas PJ. Functional esophagogastric junction obstruction with intact peristalsis: a heterogeneous syndrome sometimes akin to achalasia. J Gastrointest Surg. 2009;13(12):2219–2225. - PMC - PubMed
    1. Clayton SB, Patel R, Richter JE. Functional and Anatomic Esophagogastic Junction Outflow Obstruction: Manometry, Timed Barium Esophagram Findings, and Treatment Outcomes. Clin Gastroenterol Hepatol. 2016;14(6):907–911. - PubMed

Publication types

Substances

LinkOut - more resources