Four-dimensional impedance manometry derived from esophageal high-resolution impedance-manometry studies: a novel analysis paradigm

Abstract

Background: This study aimed to introduce a novel analysis paradigm, referred to as 4-dimensional (4D) manometry based on biophysical analysis; 4D manometry enables the visualization of luminal geometry of the esophagus and esophagogastric junction (EGJ) using high-resolution-impedance-manometry (HRIM) data.

Methods: HRIM studies from two asymptomatic controls and one type-I achalasia patient were analyzed. Concomitant fluoroscopy images from one control subject were used to validate the calculated temporal-spatial luminal radius and time-history of intraluminal bolus volume and movement. EGJ analysis computed diameter threshold for emptying, emptying time, flow rate, and distensibility index (DI), which were compared with bolus flow time (BFT) analysis.

Results: For normal control, calculated volumes for 5 ml swallows were 4.1 ml-6.7 ml; for 30 ml swallows 21.3 ml-21.8 ml. With type-I achalasia, >4 ml of intraesophageal bolus residual was present both pre- and post-swallow. The four phases of bolus transit were clearly illustrated on the time-history of bolus movement, correlating well with the fluoroscopic images. In the control subjects, the EGJ diameter threshold for emptying was 8 mm for 5 ml swallows and 10 mm for 30 ml swallows; emptying time was 1.2-2.2 s for 5 ml swallows (BFT was 0.3-3 s) and 3.25-3.75 s for 30 ml swallows; DI was 2.4-3.4 mm²/mmHg for 5 ml swallows and 4.2-4.6 mm²/mmHg for 30 ml swallows.

Conclusions: The 4D manometry system facilitates a comprehensive characterization of dynamic esophageal bolus transit with concurrent luminal morphology and pressure from conventional HRIM measurements. Calculations of flow rate and wall distensibility provide novel measures of EGJ functionality.

Keywords: 4D manometry; esophageal manometry; esophagus; intraluminal impedance; peristalsis.

Figure 1.

Pressure-impedance topography concurrent with bolus transit history of various swallows/cases. The bolus volume within the body is defined as the total calculated volume of liquid bolus between the UES and LES channels; the retention volume as the volume of liquid proximal to the CW channel but distal to the UES channel at each time. CW, contraction wave; LES, lower esophageal sphincter; UES, upper esophageal sphincter.

Figure 2.

4D manometry analysis on Control 1 against X-ray image to delineate bolus transit. (Top) A simultaneous plot of impedance, pressure, bolus volume, and retention volume history obtained by 4D manometry on Swallow #7 of Control 1. The delineation of the four-phases of bolus transit was illustrated based on bolus volume history. (Bottom) 3D rendering of esophageal luminal morphology corresponding to each phase, compared with the X-ray images below. Note that the lumen is simplified as a straight tube during the geometric construction. 3D, three-dimensional; 4D, four-dimensional.

Figure 3.

EGJ analysis of 5 ml swallows that delineate period of effective emptying. The concurrent plotting of bolus transit, EGJ pressure and diameters was used to delineate the period of effective esophageal emptying and evaluate DI listed in Table 3. DI, distensibility index; EGJ, esophagogastric junction.

Figure 4.

EGJ analysis of one swallow from Type-I Achalasia and one 30 ml swallow from Control 2. Concurrent plotting of bolus transit, EGJ pressure, and diameters was used to delineate the period of effective esophageal emptying and evaluate DI listed in Table 3 for a 30-ml swallow. DI, distensibility index; EGJ, esophagogastric junction.