Browsing by Author "Bhatia, Shobna"
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Item Chicago Classification update (V4.0): Technical review on diagnostic criteria for ineffective esophageal motility and absent contractility(2021) Gyawali, C. Prakash; Zerbib, Frank; Bhatia, Shobna; Cisternas, Daniel; Coss-Adame, Enrique; Lazarescu, Adriana; Pohl, Daniel; Yadlapati, Rena; Penagini, Roberto; Pandolfino, JohnEsophageal hypomotility disorders manifest with abnormal esophageal body contraction vigor, breaks in peristaltic integrity, or failure of peristalsis in the context of normal lower esophageal sphincter relaxation on esophageal high-resolution manometry (HRM). The Chicago Classification version 4.0 recognizes two hypomotility disorders, ineffective esophageal motility (IEM) and absent contractility, while fragmented peristalsis has been incorporated into the IEM definition. Updated criteria for ineffective swallows consist of weak esophageal body contraction vigor measured using distal contractile integral (DCI, 100–450 mmHg·cm·s), transition zone defects >5 cm measured using a 20 mmHg isobaric contour, or failure of peristalsis (DCI < 100 mmHg·cm·s). More than 70% ineffective swallows and/or ≥50% failed swallows are required for a conclusive diagnosis of IEM. When the diagnosis is inconclusive (50%–70% ineffective swallows), supplementary evidence from multiple rapid swallows (absence of contraction reserve), barium radiography (abnormal bolus clearance), or HRM with impedance (abnormal bolus clearance) could support a diagnosis of IEM. Absent contractility requires 100% failed peristalsis, consistent with previous versions of the classification. Consideration needs to be given for the possibility of achalasia in absent contractility with dysphagia despite normal IRP, and alternate complementary tests (including timed upright barium esophagram and functional lumen imaging probe) are recommended to confirm or refute the presence of achalasia. Future research to quantify esophageal bolus retention on stationary HRM with impedance and to understand contraction vigor thresholds that predict bolus clearance will provide further refinement to diagnostic criteria for esophageal hypomotility disorders in future iterations of the Chicago Classification.Item Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0(2021) Yadlapati, Rena; Kahrilas, Peter J.; Fox, Mark R.; Bredenoord, Albert J.; Gyawali, C. Prakash; Roman, Sabine; Babaei, Arash; Mittal, Ravinder K.; Rommel, Nathalie; Savarino, Edoardo; Sifrim, Daniel; Smout, André; Vaezi, Michael F.; Zerbib, Frank; Akiyama, Junichi; Bhatia, Shobna; Bor, Serhat; Carlson, Dustin A.; Chen, Joan W.; Cisternas, Daniel; Cock, Charles; Coss-Adame, Enrique; Bortoli, Nicola de; Defilippi, Claudia; Fass, Ronnie; Ghoshal, Uday C.; Gonlachanvit, Sutep; Hani, Albis; Hebbard, Geoffrey S.; Jung, Kee Wook; Katz, Philip; Katzka, David A.; Khan, Abraham; Kohn, Geoffrey Paul; Lazarescu, Adriana; Lengliner, Johannes; Mittal, Sumeet K.; Omari, Taher; Park, Moo I.; Penagini, Roberto; Pohl, Daniel; Richter, Joel E.; Serra, Jordi; Sweis, Rami; Tack, Jan; Tatum, Roger P.; Tutuian, Radu; Vela, Marcelo F.; Wong, Reuben K.; Wu, Justin C.; Xiao, Yinglian; Pandolfino, John E.Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esopha-geal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal validated methodologies over two-years to develop CCv4.0. Key updates in CCv.4.0 consist of a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, a refined definition of esophagogastric junction (EGJ) outflow obstruction (EGJOO), more stringent diag-nostic criteria for ineffective esophageal motility and description of baseline EGJ met-rics. Further, the CCv4.0 sought to define motility disorder diagnoses as conclusive and inconclusive based on associated symptoms, and findings on provocative testing as well as supportive testing with barium esophagram with tablet and/or functional lumen imaging probe. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification and provide more standardized and rigorous criteria for pat-terns of disorders of peristalsis and obstruction at the EGJItem Esophagogastric junction morphology and contractile integral on high-resolution manometry in asymptomatic healthy volunteers: An international multicenter study(2021) Rogers, Benjamin D.; Rengarajan, Arvind; Abrahao, Luiz; Bhatia, Shobna; Bor, Serhat; Carlson, Dustin A.; Cisternas, Daniel; Gonlachanvit, SutepBackground: Esophagogastric junction contractile integral (EGJ-CI) and EGJ mor -phology are high-resolution manometry (HRM) metrics that assess EGJ barrier func -tion. Normative data standardized across world regions and HRM manufacturers are limited.Methods: Our aim was to determine normative EGJ metrics in a large international cohort of healthy volunteers undergoing HRM (Medtronic, Laborie, and Diversatek software) acquired from 16 countries in four world regions. EGJ-CI was calculated by the same two investigators using a distal contractile integral-like measurement across the EGJ for three respiratory cycles and corrected for respiration (mm Hg cm), using manufacturer-specific software tools. EGJ morphology was designated according to Chicago Classification v3.0. Median EGJ-CI values were calculated across age, gen -ders, HRM systems, and regions.Results: Of 484 studies (28.0 years, 56.2% F, 60.7% Medtronic studies, 26.0% Laborie, and 13.2% Diversatek), EGJ morphology was type 1 in 97.1%. MedianEGJ-CI was similar between Medtronic (37.0 mm Hg cm, IQR 23.6-53.7 mm Hg cm) and Diversatek (34.9 mm Hg cm, IQR 22.1-56.1 mm Hg cm, P = 0.87), but was signif-icantly higher using Laborie equipment (56.5 mm Hg cm, IQR 35.0-75.3 mm Hg cm, P < 0.001). 5th percentile EGJ-CI values ranged from 6.9 to 12.1 mm Hg cm. EGJ-CI values were consistent across world regions, but different between manufacturers even within the same world region (P ≤ 0.001). Within Medtronic studies, EGJ-CIand basal LESP were similar in younger and older individuals (P ≥ 0.3) but higher in women (P < 0.001).Conclusions: EGJ morphology is predominantly type 1 in healthy adults. EGJ-CI varies widely in health, with significant gender influence, but is consistent within each HRM system. Manufacturer-specific normative values should be utilized for clinical HRM interpretation.Publication High-resolution manometry thresholds and motor patterns among asymptomatic individuals.(2022) Rengarajan, Arvind; Rogers, Benjamin D.; Wong, Zhiqin; Tolone, Salvatore; Sifrim, Daniel; Serra, Jordi; Savarino, Edoardo; Roman, Sabine; Remes-Troche, Jose M.; Ramos, Rosa; Perez de la Serna, Julio; Pauwels, Ans; Leguizamo, Ana Maria; Yeh Lee, Yeong; Kawamura, Osamu; Hayat, Jamal; Hani, Albis; Gonlachanvit, Sutep; Cisternas, Daniel; Cisternas, Daniel; Carlson, Dustin; Bor, Serhat; Bhatia, Shobna; Abrahao, Luiz; Pandolfino, John; Gyawali, C. PrakashObjective: High-resolution manometry (HRM) is the current standard for characterization of esophageal body and esophagogastric junction (EGJ) function. We aimed to examine the prevalence of abnormal esophageal motor patterns in health, and to determine optimal thresholds for software metrics across HRM systems. Design: Manometry studies from asymptomatic adults were solicited from motility centers worldwide, and were manually analyzed using integrated relaxation pressure (IRP), distal latency (DL), and distal contractile integral (DCI) in standardized fashion. Normative thresholds were assessed using fifth and/or 95th percentile values. Chicago Classification v3.0 criteria were applied to determine motor patterns across HRM systems, study positions (upright vs supine), ages, and genders. Results: Of 469 unique HRM studies (median age 28.0, range 18-79 years). 74.6% had a normal HRM pattern; none had achalasia. Ineffective esophageal motility (IEM) was the most frequent motor pattern identified (15.1% overall), followed by EGJ outflow obstruction (5.3%). Proportions with IEM were lower using stringent criteria (10.0%), especially in supine studies (7.1%-8.5%). Other motor patterns were rare (0.2%-4.1% overall) and did not vary by age or gender. DL thresholds were close to current norms across HRM systems, while IRP thresholds varied by HRM system and study position. Both fifth and 95th percentile DCI values were lower than current thresholds, both in upright and supine positions. Conclusions: Motor abnormalities are infrequent in healthy individuals and consist mainly of IEM, proportions of which are lower when using stringent criteria in the supine position. Thresholds for HRM metrics vary by HRM system and study position.Publication Updates to the modern diagnosis of GERD: Lyon consensus 2.0(2023) Gyawali, Prakash; Yadlapati, Rena; Fass, Ronnie; Katzka, David; Pandolfino, John; Savarino, Edoardo; Sifrim, Daniel; Spechler, Stuart; Zerbib, Frank; Fox, Mark; Bhatia, Shobna; De Bortoli, Nicola; Kyung Cho, Yu; Cisternas, Daniel; Chen, Chien-Lin; Cock, Charles; Hani, Albis; Remes, Jose; Xiao, Yinglian; Vaezi, Michael; Roman, SabineThe Lyon Consensus provides conclusive criteria for and against the diagnosis of gastro-oesophageal reflux disease (GERD), and adjunctive metrics that consolidate or refute GERD diagnosis when primary criteria are borderline or inconclusive. An international core and working group was assembled to evaluate research since publication of the original Lyon Consensus, and to vote on statements collaboratively developed to update criteria. The Lyon Consensus 2.0 provides a modern definition of actionable GERD, where evidence from oesophageal testing supports revising, escalating or personalising GERD management for the symptomatic patient. Symptoms that have a high versus low likelihood of relationship to reflux episodes are described. Unproven versus proven GERD define diagnostic strategies and testing options. Patients with no prior GERD evidence (unproven GERD) are studied using prolonged wireless pH monitoring or catheter-based pH or pH-monitoring off antisecretory medication, while patients with conclusive GERD evidence (proven GERD) and persisting symptoms are evaluated using pH-impedance monitoring while on optimised antisecretory therapy. The major changes from the original Lyon Consensus criteria include establishment of Los Angeles grade B oesophagitis as conclusive GERD evidence, description of metrics and thresholds to be used with prolonged wireless pH monitoring, and inclusion of parameters useful in diagnosis of refractory GERD when testing is performed on antisecretory therapy in proven GERD. Criteria that have not performed well in the diagnosis of actionable GERD have been retired. Personalisation of investigation and management to each patient's unique presentation will optimise GERD diagnosis and management.