Browsing by Author "Gyawali, C. Prakash"
Now showing 1 - 4 of 4
Results Per Page
Sort Options
Item Breaks in peristaltic integrity predict abnormal esophageal bolus clearance better than contraction vigor or residual pressure at the esophagogastric junction(2021) Rogers, Benjamin D.; Cisternas, Daniel; Rengarajan, Arvind; Marin, Ingrid; Abrahao Jr, Luiz; Hani,Albis; Lequizamo, Ana M.; Remes-Troche, José M.; Perez de la Serna, Julio; Ruiz de Leon, Antonio; Zerbib, Frank; Serra, Jordi; Gyawali, C. PrakashBackground: High- resolution impedance manometry (HRIM) evaluates esophagealperistalsis and bolus transit. We used esophageal impedance integral (EII), the ratio between bolus presence before and after an expected peristaltic wave, to evaluate predictors of bolus transit. Methods: From HRIM studies performed on 61 healthy volunteers (median age 27 years, 48%F), standard metrics were extracted from each of 10 supine water swallows: distal contractile integral (DCI, mmHg cm s), integrated relaxation pressure(IRP, mmHg), and breaks in peristaltic integrity (cm, using 20 mmHg isobaric contour). Pressure and impedance coordinates for each swallow were exported into a dedi -cated, python- based program for EII calculation (EII ratio ≥ 0.3 = abnormal bolus clear -ance). Univariate and multivariate analyses were performed to assess predictors of abnormal bolus clearance. Key Results: Of 591 swallows, 80.9% were intact, 10.5% were weak, and 8.6% failed. Visual analysis overestimated abnormal bolus clearance compared to EII ratio (p ≤ 0.01). Bolus clearance was complete (median EII ratio 0.0, IQR 0– 0.12) in 82.0% of intact swallows in contrast to 53.3% of weak swallows (EII ratio 0.29, IQR 0.0– 0.57), and 19.6% of failed swallows (EII ratio 0.5, IQR 0.34– 0.73, p < 0.001). EII correlated best with break length (ρ = 0.52, p < 0.001), compared to IRP (ρ: −0.17) or DCI (ρ: −0.42). On ROC analysis, breaks predicted abnormal bolus transit better than DCI or IRP (AUC 0.79 vs. 0.25 vs. 0.44, p ≤ 0.03 for each). On logistic regression, breaks remained independently predictive of abnormal bolus transit (p < 0.001). Conclusions & Inferences: Breaks in peristaltic integrity predict abnormal bolus clear-ance better than DCI or IRP in healthy asymptomatic subjects.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 EGJPublication 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.