Journal of Neurogastroenterology and Motility最新文献

Background/aims: Assessment of treatment response of achalasia often involves multiple procedures. We aim to investigate innovative metrics based on 4-dimensional high-resolution impedance manometry (4D HRM) to assess treatment response in achalasia patients.

Methods: Patients with achalasia treated by pneumatic dilation or myotomy who underwent follow-up evaluations were included. All patients completed high-resolution impedance manometry before and after treatment. 4D HRM analysis based on developed python program measured clearance ratio, intrabolus pressure (IBP), maximum esophagogastric junction diameter, and distensibility index. Good treatment outcomes were defined as barium column height of < 5 cm at 5 minutes on timed barium esophagram (TBE) and Eckardt score ≤ 3.

Results: Fifty-three patients with achalasia were included: 40% type I, 51% type II, and 9% type III. Change of clearance ratio and IBP on 4D HRM had superior performance in predicting abnormal TBE at 5 minutes (area under the receiver operating characteristic [AUROC] curve, 95% confidence interval: 0.76, 0.59-0.93; 0.74, 0.57-0.92). The combination of clearance ratio (increase with a threshold of 0.1) and IBP (reduction with a threshold of 8.9 mmHg) had a high positive predictive value for normal TBE outcome (93%), and a modest negative predictive value for abnormal TBE outcome (73%). Receiver operating characteristics of metrics related to poor symptomatic outcome only yielded AUROCs (95% CI) of 0.82 (0.68-0.96) for esophageal hypervigilance and anxiety scale posttreatment.

Conclusions: IBP and clearance ratio help to identify abnormal barium retention in patients after treatment. 4D manometry can be an alternative or complementary approach to characterize and assess treatment response of Achalasia, in additional to TBE or functional lumen imaging probe.

Background/aims: Chronic intestinal pseudo-obstruction (CIPO), characterized by dilated small or large intestine on CT, has a high postoperative recurrence rate. In contrast, focal hypoganglionosis with adult-onset megacolon (FHAM) generally shows a good postoperative prognosis. This study aims to evaluate the utility of cine-MRI in differentiating between these 2 diseases by assessing small bowel (SB) motility and its correlation with clinical outcomes.

Methods: The clinical features and outcomes of 41 prospectively enrolled patients suspected of having CIPO who underwent cine-MRI were reviewed. Multi-slice cine-MRI was conducted.

Results: Of 41 patients suspected of having CIPO, 17 showed SB dilatation on CT, while 24 did not. According to cine-MRI, 3 exhibited decreased SB motility, while 38 showed no motility reduction. Among the 17 patients with dilated SB on CT, only 3 demonstrated decreased SB motility on cine-MRI. By contrast, all patients with nondilated SB on CT exhibited normal SB motility on cine-MRI. Patients with decreased SB motility showed a higher rate of postoperative disease recurrence (P = 0.011) and continuation of medication after surgery (P = 0.020) than in those with normal SB motility.

Conclusions: Cine-MRI is useful in assessing SB motility that cannot be detected on CT. Its usefulness extends to aiding surgical decision-making, particularly in differentiating between FHAM and CIPO.

Background/aims: The Chicago classification version 4.0 (CC v4.0) proposes a standardized high-resolution manometry protocol for more sophisticated diagnosis of esophageal motility disorders. We aim to investigate the real-world application of CC v4.0 through multi-institutional surveys in Asian countries.

Methods: We requested a total of 161 questionnaires from members of the Asian Neurogastroenterology and Motility Association via Google Survey from March to June 2023. The questionnaire assessed CC v4.0 protocol compliance and diagnosis.

Results: Responses were received from 33 centers in 9 countries (18 in Korea, 5 in Japan, and 10 in others). Among these, anticholinergics were investigated in 14 centers (42.4%), and narcotic drugs in 16 centers (48.5%). Eight centers (24.2%) fully adhered to CC v4.0 protocol for single wet swallows and provocation tests. Nine centers (27.3%) had an adaptation period < 60 seconds, 13 centers (39.4%) had < 3 breath counts, and 15 centers (45.5%) had swallowing intervals < 30 seconds (42.4% had 10-29 seconds and 3% had < 10 seconds). Twenty-four centers (72.7%) started the examination in a supine position and 13 centers (39.4%) did not change their position. Among 27 centers (81.8%) applying provocation tests, all applied multiple rapid swallows, whereas rapid drink challenge was applied in 19 (57.6%). Timed barium esophagography and functional lumen imaging probe were available in 16 (48.5%) and 6 centers (18.2%), respectively.

Conclusions: We observed heterogeneity among centers in the application of CC v4.0 protocol. To increase inter-center reliability and minimize diagnostic ambiguity, efforts should continue toward the practical clinical application of standard protocols.

Background/aims: The Lyon Consensus 2.0 (Lyon 2.0) revised gastroesophageal reflux disease (GERD) definitions, incorporating Los Angeles (LA) grade B as diagnostic and mean nocturnal basal impedance (MNBI) as supplementary evidence. Asian populations show differing impedancepH thresholds, with lower acid exposure time (AET) and higher MNBI values. The clinical validity of MNBI in Asian GERD patients remains uncertain. This study evaluated Lyon 2.0's applicability to Korean patients.

Methods: From January 2021 to August 2023, GERD-suspected patients underwent endoscopy, manometry, and pH testing. MNBI was measured 5 cm above the lower esophageal sphincter. Patients with major motor disorders, organic diseases, or prior foregut surgery were excluded. GERD was defined by AET ≥ 4% or LA grades B-D; non-GERD by AET < 4%, LA grade A or normal Z line with < 40 reflux episodes/day. The optimal MNBI threshold was determined via receiver operating characteristic curve analysis.

Results: Among 427 patients (mean age 57.7 ± 13.8 years, 37.2% male), 59 (13.8%) had GERD (10 endoscopically confirmed, 54 by AET ≥ 4%). Non-GERD accounted for 63.5% (n = 271), with 22.7% (n = 97) in the borderline group. MNBI correlated negatively with AET (r = -0.482, P < 0.01) and LA grade (r = -1.390, P = 0.005). The optimal MNBI threshold for GERD was 2167 Ω (sensitivity 0.86, specificity 0.75). Three LA grade A cases were reclassified as GERD-positive using this threshold.

Conclusion: MNBI significantly correlated with AET and LA grades, highlighting its diagnostic value in Korean GERD patients. However, regional variations suggest higher MNBI thresholds than Lyon 2.0 recommendations, warranting further studies to refine criteria for Asian populations.

Background/aims: This study evaluates the clinical significance of the gastric emptying time (GET) in patients with functional dyspepsia (FD).

Methods: This retrospective study included 89 patients who visited the clinic with indigestion between 2021 and 2022. FD was diagnosed and categorized into 3 subtypes: postprandial distress syndrome, epigastric pain syndrome, and overlap type, following the Rome IV criteria. GET was assessed using ^99mTc scintigraphy. The stomach remnant was measured 1 and 2 hours after ingesting a technetium-99m labeled egg, and the time required for the remnant to decrease by half (T_1/2) was calculated.

Results: Of the 89 patients studied, 46 were diagnosed with FD. The remaining 43 patients, who did not meet the Rome IV criteria, were included as the control group. Patients with FD exhibited a higher incidence of smoking, a higher body mass index, and a higher incidence of diabetes than the non-FD group. GET and T_1/2 did not show significant differences between the 2 groups (P = 0.240 and P = 0.126, respectively). However, the FD group exhibited a smaller gastric retention rate than the non-FD group at all time points. In the subtype analysis, GET and T_1/2 were not significantly different among the 3 subtypes (P = 1.000 and P = 0.173, respectively). Diabetes mellitus, current smoking status, elevated body mass index, and younger age were significantly associated with FD.

Conclusion: GET did not significantly differ among FD patients or its subtypes, despite a lower gastric retention rate in FD patients.

High-resolution manometry (HRM) has revolutionized evaluation of esophageal motility disorders, offering detailed pressure topography and refined diagnostic criteria codified through the Chicago classification (CC). However, patients with dysphagia may present with borderline or near-normal HRM findings, exhibiting clinically significant symptoms. CC version 4.0 (v4.0) addresses such scenarios by recommending provocative maneuvers and ancillary tests, notably functional lumen imaging probe (FLIP) and timed barium esophagography. However, growing evidence indicates that FLIP, which measures luminal distensibility under balloon distention, can detect structural or biomechanical abnormalities, such as hypertrophy or fibrosis, that remain inconspicuous on HRM. These discordant findings point to limitations in CC v4.0. FLIP complements HRM by assessing passive tissue properties and capturing balloon-induced contractility, thereby unmasking subtle esophageal wall stiffness not always reflected in integrated relaxation pressure or standard peristaltic metrics. Such discrepancies can arise in early or atypical achalasia, esophagogastric junction outflow obstruction, eosinophilic esophagitis, and even epiphrenic diverticula, where "normal" manometry may belie significant pathology. Present CC v4.0 guidelines do not specify how to incorporate FLIP-derived measures or reconcile disagreements with timed barium esophagography results, leaving certain phenotypes-including repetitive simultaneous contractions-under-recognized. These gaps underscore an overreliance on integrated relaxation pressure alone and insufficient integration of evolving FLIP technology. Thus, standardizing FLIP protocols, establishing normative distensibility data, and clarifying management pathways for manometry-FLIP discordance remain critical. Prospective, multicenter studies are needed to investigate long-term clinical outcomes and to refine how FLIP metrics can be formally integrated into future CC iterations. Ultimately, multimodal, symptom-driven approaches that leverage both HRM and FLIP are essential to fully characterize esophageal dysmotility and optimize therapy.

Background/aims: Patients with ulcerative colitis in remission (UC-R) may experience symptoms consistent with irritable bowel syndrome (IBS). This prospective study aims to examine the relative influence of peripheral factors, such as gut mucosal inflammation, and central factors, like psychological conditions, on the severity of IBS symptoms to evaluates (1) the IBS Symptom Severity Score (IBS-SSS), (2) levels of inflammatory markers, and (3) the presence of psychological comorbidities across 3 groups: UC patients with IBS symptoms (UC-IBS), UC-R patients without IBS, and individuals with usual IBS.

Methods: Rome III and IV IBS criteria were used in UC-R patients (Mayo score 0), with symptom severity measured by IBS-SSS. Serum and fecal inflammation markers were compared across UC-R without IBS, UC-IBS, and IBS groups.

Results: Among UC-R patients, 31.3% (26/83) met Rome III and 9.6% (8/83) met Rome IV IBS criteria. IBS-SSS scores were significantly lower in UC-IBS compared to IBS (n = 50; 167.5 [150-200] vs 255 [225-325]; P < 0.001). Fecal calprotectin levels were higher in UC-IBS than in UC-R or IBS (62.6 μg/g [34.1-85.6] vs 50.6 μg/g [27.3-96.6] vs 37.6 μg/g [12.1-62.3], P = 0.057), while other fecal markers (lactoferrin and MMP-9) showed no significant differences between UC-IBS and UC-R. Serum inflammatory marker including tumor necrosis factor-alpha, interleukin-6, interleukin-10, and granulocyte-macrophage colony-stimulating factor, C-reactive protein were similar across groups. Patients with IBS reported significantly higher anxiety, pain, functional impairment, and coping difficulties (all P < 0.001) compared to UC-IBS, with the lowest levels observed in UC-R without IBS.

Conclusions: One-third and one-tenth of UC-R patients met Rome III and IV IBS criteria, respectively. UC-IBS had lower IBS-SSS and higher fecal calprotectin than IBS. Psychological comorbidities were worse in IBS, least in UC-R without IBS, suggesting more peripheral inflammation and less central involvement in UC-IBS.