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Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium
Author(s) -
Gyawali C. Prakash,
Sifrim Daniel,
Carlson Dustin A.,
Hawn Mary,
Katzka David A.,
Pandolfino John E.,
Penagini Roberto,
Roman Sabine,
Savarino Edoardo,
Tatum Roger,
Vaezi Michel,
Clarke John O.,
Triadafilopoulos George
Publication year - 2019
Publication title -
neurogastroenterology and motility
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.489
H-Index - 105
eISSN - 1365-2982
pISSN - 1350-1925
DOI - 10.1111/nmo.13584
Subject(s) - high resolution manometry , peristalsis , medicine , reflux , esophageal motility disorder , supine position , motility , asymptomatic , swallowing , gastroenterology , dysphagia , cardiology , esophagus , bolus (digestion) , disease , surgery , biology , genetics
Background Ineffective esophageal motility (IEM) is a heterogenous minor motility disorder diagnosed when ≥50% ineffective peristaltic sequences (distal contractile integral <450 mm Hg cm s) coexist with normal lower esophageal sphincter relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high‐resolution manometry (HRM). Ineffective esophageal motility is not consistently related to disease states or symptoms and may be seen in asymptomatic healthy individuals. Purpose A 1‐day symposium of esophageal experts reviewed existing literature on IEM, and this review represents the conclusions from the symposium. Severe IEM (>70% ineffective sequences) is associated with higher esophageal reflux burden, particularly while supine, but milder variants do not progress over time or consistently impact quality of life. Ineffective esophageal motility can be further characterized using provocative maneuvers during HRM, especially multiple rapid swallows, where augmentation of smooth muscle contraction defines contraction reserve. The presence of contraction reserve may predict better prognosis, lesser reflux burden and confidence in a standard fundoplication for surgical management of reflux. Other provocative maneuvers (solid swallows, standardized test meal, rapid drink challenge) are useful to characterize bolus transit in IEM. No effective pharmacotherapy exists, and current managements target symptoms and concurrent reflux. Novel testing modalities (baseline and mucosal impedance, functional lumen imaging probe) show promise in elucidating pathophysiology and stratifying IEM phenotypes. Specific prokinetic agents targeting esophageal smooth muscle need to be developed for precision management.