Background The diagnosis of esophagogastric outflow obstruction (EGJOO) is a pathological manometric condition. It is observed in 5 to 24% of patients undergoing high-resolution esophageal manometry. Although relatively common, most patients do not require therapy. In order to identify clinically significant cases, the recent Chicago Classification v4.0 has refined diagnostic criteria by integrating data from esophagography and/or endoFLIP. However, these methods have several limitations. Esophageal pH impedance monitoring, routinely used for diagnosing gastroesophageal reflux disease, can provide information on luminal stasis in the distal esophagus and EGJ relaxation, likely reflecting the quantity of gastroesophageal reflux and the acid content in the distal esophagus. Purpose of study The main objective of this retrospective observational study is to evaluate the capability of esophageal pH impedance monitoring to identify patients with EGJOO, specifically as an additional test for recognizing clinically significant cases. The widespread use of this method, along with its low cost and easy availability in physiopathology clinics, makes it potentially suitable for this application. A secondary aim of this study is related to the possibility of identifying, among the EGJOO patient population, those individuals who over the years would develop a manometric pattern of achalasia. Methods and Materials The database used for the reference sample consists of 1817 individuals, collecting data from 2013 to 2023 from patients who underwent high-resolution manometry (HRM) or esophageal pH impedance monitoring at our hospital. Demographic characteristics, data from HRM and esophageal pH impedance analysis, as well as information from endoscopic and radiological esophageal investigations, and symptomatology were analyzed. Four different patient groups were identified: patients with a manometric diagnosis of EGJOO and typical symptoms (dysphagia and/or chest pain) (population 1), patients with a diagnosis of EGJOO without typical symptoms (population 2), normal subjects (normal HRM and pH impedance), and patients with a diagnosis of achalasia (population 4). The main parameters analyzed were related to esophageal acid exposure (aet) and the number of reflux episodes. Statistical tests used for data analysis were ANOVA for continuous variables and Chi-square for categorical variables, using R. Results Out of the 1817 patients in the database, 113 received a manometric diagnosis of EGJOO, including 35 patients with typical symptoms (population 1) and 13 with a manometric diagnosis unsupported by specific symptoms (population 2). 160 individuals had a normal manometric and pH impedance diagnosis (normal population). Among the 117 subjects with a manometric diagnosis of achalasia, 10 patients had pH impedance data (population 4). Analysis of variables in the database and their distribution revealed a significant increase in aet in patients with EGJOO compared to healthy controls (p=0.02). No statistically significant difference was found between subjects with EGJOO with and without typical symptoms, in comparison to subjects with achalasia. Conclusions The data obtained in this preliminary work did not lead to unequivocal results regarding the potential use of pH impedance monitoring as an additional test for identifying clinically relevant EGJOO cases. However, it is possible that the retained bolus is perceived as acidic content, but further evaluations are needed to confirm this hypothesis. Additional studies and exploration of new parameters (e.g., postprandial impedance) are necessary to assess the actual utility of this method in this application.
Introduzione La diagnosi di ostruzione al deflusso esofago gastrico è un quadro manometrico patologico. Viene riscontrato tra il 5 e il 24% dei pazienti che svolgono una HRM, ma pur essendo un quadro relativamente frequente, la maggior parte dei pazienti non necessità di terapia. Al fine di identificare i quadri clinicamente significativi, la recente Classificazione di Chicago v4.0 ha reso più rigorosi i criteri diagnostici, integrando i dati dell’esofagogramma e/o dell’endoFLIP, per la diagnosi. Queste metodiche tuttavia presentano diversi limiti. La pH impedenziometria esofagea, routinariamente utilizzata per la diagnosi di malattia da reflusso gastroesofageo, può fornire informazioni sul ristagno endoluminale in esofago distale e sul rilassamento dell’EGJ, che verosimilmente si riflette sulla quantità di reflussi gastro-esofagei e sulla quota di acido in esofago distale. Scopo dello studio Lo scopo principale di questo studio osservazionale retrospettivo è di valutare la capacità della pH-impedenziometria esofagea di identificare i pazienti con EGJOO e, nello specifico di poter essere utilizzata come test aggiuntivo per il riconoscimento dei quadri clinicamente significativi. La diffusione della metodica in aggiunta ai bassi costi e alla facile disponibilità negli ambulatori di fisiopatologia rendono questa metodica potenzialmente adatta a questa applicazione. Un aim secondario di questo studio è legato alla possibilità di intercettare tra la popolazione di pazienti affetti da EGJOO, quegli individui che negli anni avrebbero sviluppato un quadro manometrico di Acalasia. Materiali e metodi Il database da cui abbiamo preso il campione di riferimento è formato di 1817 individui, raccoglie dati dal 2013 al 2023 tra i pazienti che si sono sottoposti ad HRM o pH-impedenziometria presso la nostra struttura. Sono state quindi prese in analisi le caratteristiche demografiche della popolazione, collezionati i dati ottenuti dalle analisi di HRM e pH impedenzometria esofagea. Venivano inoltre collezionati dati da indagini endoscopiche, radiologiche dell’esofago, e sulla sintomatologia. Sono quindi state identificati 4 diversi gruppi di pazienti: i pazienti con diagnosi manometrica di EGJOO e sintomatologia tipica (disfagia e/o dolore toracico) (popolazione 1), i pazienti con diagnosi di EGJOO senza sintomatologia tipica (popolazione 2), i soggetti normali (HRM e pH-imp nella norma) e i pazienti con diagnosi di acalasia (popolazione 4). I parametri principali presi in analisi sono legati all’esposizione all’acido esofagea (aet) e il numero di reflussi. I test statistici utilizzati per l’analisi dei dati sono stati Anova per le variabili continue e Chi Quadrato per le variabili categoriche, tramite R. Risultati Dei 1817 pazienti presenti nel database, 113 hanno ricevuto diagnosi manometrica di EGJOO, di cui 35 pazienti con sintomatologia tipica (popolazione 1) e 13 con diagnosi manometrica non supportata da sintomatologia specifica (popolazione 2). 160 individui presentano diagnosi manometrica e pH-impedenziometrica normale (popolazione normale). Di 117 soggetti con diagnosi manometrica di acalasia, 10 pazienti presentavano i dati pH-impedenziometrici (popolazione 4). L’analisi delle variabili e della loro distribuzione ha evidenziato un significativo aumento dell’aet nei pazienti con EGJOO rispetto ai controlli sani (p=0.02). Non è stata riscontrata una differenza statisticamente significativa tra soggetti con EGJOO con e senza sintomatologia tipica e nei confronti dei soggetti con acalasia. Conclusioni I dati ottenuti in questo lavoro preliminare non hanno portato a risultati univoci riguardo un potenziale utilizzo della pH-impedenziometria come test aggiuntivo per l’identificazione dei quadri di EGJOO clinicamente rilevanti. È tuttavia possibile che il bolo ritenuto venga percepito come contenuto acido, ma ulteriori valutazioni sono necessarie per confermare questa ipotesi.
Il ruolo della pH-impedenziometria nella diagnosi di Ostruzione della Giunzione Esofago-Gastrica secondo la classificazione di Chicago
FERRARESE, GABRIELE
2022/2023
Abstract
Background The diagnosis of esophagogastric outflow obstruction (EGJOO) is a pathological manometric condition. It is observed in 5 to 24% of patients undergoing high-resolution esophageal manometry. Although relatively common, most patients do not require therapy. In order to identify clinically significant cases, the recent Chicago Classification v4.0 has refined diagnostic criteria by integrating data from esophagography and/or endoFLIP. However, these methods have several limitations. Esophageal pH impedance monitoring, routinely used for diagnosing gastroesophageal reflux disease, can provide information on luminal stasis in the distal esophagus and EGJ relaxation, likely reflecting the quantity of gastroesophageal reflux and the acid content in the distal esophagus. Purpose of study The main objective of this retrospective observational study is to evaluate the capability of esophageal pH impedance monitoring to identify patients with EGJOO, specifically as an additional test for recognizing clinically significant cases. The widespread use of this method, along with its low cost and easy availability in physiopathology clinics, makes it potentially suitable for this application. A secondary aim of this study is related to the possibility of identifying, among the EGJOO patient population, those individuals who over the years would develop a manometric pattern of achalasia. Methods and Materials The database used for the reference sample consists of 1817 individuals, collecting data from 2013 to 2023 from patients who underwent high-resolution manometry (HRM) or esophageal pH impedance monitoring at our hospital. Demographic characteristics, data from HRM and esophageal pH impedance analysis, as well as information from endoscopic and radiological esophageal investigations, and symptomatology were analyzed. Four different patient groups were identified: patients with a manometric diagnosis of EGJOO and typical symptoms (dysphagia and/or chest pain) (population 1), patients with a diagnosis of EGJOO without typical symptoms (population 2), normal subjects (normal HRM and pH impedance), and patients with a diagnosis of achalasia (population 4). The main parameters analyzed were related to esophageal acid exposure (aet) and the number of reflux episodes. Statistical tests used for data analysis were ANOVA for continuous variables and Chi-square for categorical variables, using R. Results Out of the 1817 patients in the database, 113 received a manometric diagnosis of EGJOO, including 35 patients with typical symptoms (population 1) and 13 with a manometric diagnosis unsupported by specific symptoms (population 2). 160 individuals had a normal manometric and pH impedance diagnosis (normal population). Among the 117 subjects with a manometric diagnosis of achalasia, 10 patients had pH impedance data (population 4). Analysis of variables in the database and their distribution revealed a significant increase in aet in patients with EGJOO compared to healthy controls (p=0.02). No statistically significant difference was found between subjects with EGJOO with and without typical symptoms, in comparison to subjects with achalasia. Conclusions The data obtained in this preliminary work did not lead to unequivocal results regarding the potential use of pH impedance monitoring as an additional test for identifying clinically relevant EGJOO cases. However, it is possible that the retained bolus is perceived as acidic content, but further evaluations are needed to confirm this hypothesis. Additional studies and exploration of new parameters (e.g., postprandial impedance) are necessary to assess the actual utility of this method in this application.File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.12608/60852