Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium

C. Prakash Gyawali, Daniel Sifrim, Dustin A. Carlson, Mary Hawn, David A Katzka, John E. Pandolfino, Roberto Penagini, Sabine Roman, Edoardo Savarino, Roger Tatum, Michel Vaezi, John O. Clarke, George Triadafilopoulos

Research output: Contribution to journalReview article

1 Citation (Scopus)

Abstract

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.

Original languageEnglish (US)
Article numbere13584
JournalNeurogastroenterology and Motility
DOIs
StatePublished - Jan 1 2019

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Swallows
Smooth Muscle
Fundoplication
Gastroesophageal Reflux
Muscle Contraction
Electric Impedance
Meals
Quality of Life
Phenotype
Drug Therapy
Direction compound

Keywords

  • contraction reserve
  • dysphagia
  • gastroesophageal reflux disease
  • high-resolution manometry
  • ineffective esophageal motility
  • multiple rapid swallows

ASJC Scopus subject areas

  • Physiology
  • Endocrine and Autonomic Systems
  • Gastroenterology

Cite this

Ineffective esophageal motility : Concepts, future directions, and conclusions from the Stanford 2018 symposium. / 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.

In: Neurogastroenterology and Motility, 01.01.2019.

Research output: Contribution to journalReview article

Gyawali, CP, Sifrim, D, Carlson, DA, Hawn, M, Katzka, DA, Pandolfino, JE, Penagini, R, Roman, S, Savarino, E, Tatum, R, Vaezi, M, Clarke, JO & Triadafilopoulos, G 2019, 'Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium', Neurogastroenterology and Motility. https://doi.org/10.1111/nmo.13584
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. / Ineffective esophageal motility : Concepts, future directions, and conclusions from the Stanford 2018 symposium. In: Neurogastroenterology and Motility. 2019.
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abstract = "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.",
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AU - Gyawali, C. Prakash

AU - Sifrim, Daniel

AU - Carlson, Dustin A.

AU - Hawn, Mary

AU - Katzka, David A

AU - Pandolfino, John E.

AU - Penagini, Roberto

AU - Roman, Sabine

AU - Savarino, Edoardo

AU - Tatum, Roger

AU - Vaezi, Michel

AU - Clarke, John O.

AU - Triadafilopoulos, George

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N2 - 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.

AB - 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.

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