Esophageal Motility Characteristics In Refractory Gastro-esophageal Reflux Disease Patients And The Value Of Different Swallowing Tests In Esophageal Manometry

Background:With wild application of proton pump inhibitors (PPIs), most Gastro-esophageal reflux disease (GERD) patients’symptoms have been well controlled. However, there are still some patients who don’t respond to PPIs well. This is called Refractory GERD. There are many factors involved in refractory GERD. Esophageal motility disorder is one of them. With the application of High resolution manometry (HRM), the detection rate has been improved. However, conventional method’s sensitivity still needs to be improved. Recent studies about free drinking and solid swallow tests showed that different swallowing tests can be supplement tests to the conventional method. But these studies haven’t been done among Chinese population.Objective:To analyze the esophageal motility characteristics of refractory gastro-esophageal reflux disease (GERD) patients and explore the value of different swallowing tests in high resolution manometry (HRM).Methods:We retrospectively analyzed data of patients with typical symptoms of GERD enrolled in Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University from January2012to April2014. Those patients were divided into three groups of reflux esophagitis (RE), non-erosive reflux disease (NERD) and no symptom-reflux association group according to the results of gastroscopy and24hour pH-impedance monitoring. Esophageal motility characteristics of the included patients were drawn from HRM and the diagnosis of esophageal motility disorder were made according to the Chicago Classification V3.0. The detection rates were compared between different swallowing tests using Wilcoxon paired test.Results:Finally44patients were enrolled, with10RE patients,23NERD patients and11no symptom-reflux association patients.(1) The median acidic reflux events of RE group (23.0) was significantly larger than NERD group (11.0) and no symptom-reflux association group (7.0)(p<0.05). The median acidic exposure time of RE group (33.5) was significantly larger than NERD group (5.0) and no symptom-reflux association group (4.0)(p<0.05).(2) The IRP of RE patients (7.0mmHg) were significantly lower than those of NERD patients (9.1mmHg) and no symptom-reflux association group (9.1mmHg)(p<0.05).(3) Esophageal motility disorders were found in21of the44enrolled patients (47.7%), and Ineffective esophageal motility (IEM) is the most common type (11/21,52.4%). Besides, other types of esophageal motility disorders were also observed including fragmented peristalsis (FP)(8/21,38.1%),absent contractility(1/21,4.8%)and Jackhammer esophagus (1/21,4.8%). The overall rate of esophageal motility disorders was similar among three groups (RE50%, NERD39.1%and non-reflux symptom group63.6%).(4) Esophageal motility disorders detection rate was significantly higher using free drinking (200ml water)(31/44,70.5%) than using conventional method (10*5ml water swallow)(21/44,47.7%)(p<0.05).(5) Higher detection rate was not observed using solid swallow.Conclusions:Esophageal motility disorders were common in refractory GERD patients, in which IEM is the most common type. Esophageal motility disorders detection rate was higher using free drinking (200ml water) than conventional method. More studies are warranted to further evaluate the value of free drinking method.