The Value Of Three Different Test Meal In High-resolution Manometry For Assessment Of The Esophageal Dysfunction In Refractory Gastro-esophageal Reflux Disease(GERD)Patients

Background:Gastroesophageal reflux disease (GERD) is a common digestive disease, the pathophysiological mechanism of which is still unclear. Recently, GERD is recognized as a pathological condition of gastrointestinal motility disorder. With the development of proton pump inhibitor (PPI), the treatment of GERD has been greatly improved. However, there is still a small portion of this diseases, so called refractory GERD, that can not be intervened effectively by PPI. High-resolution manometry (HRM) is a straightforward and precise pressure measuring method developed from the traditional esophagus pressure detection. Current HRM protocols establish diagnoses using normal values obtained from 5 ml water swallows,50ml water drink. However, the disadvantage of this method is that it is hard to induce the gastrointestinal motility disorder in patients due to its low match to normal physiological habit. This protocol often fail to explain the relationship between the symptom and pathogenesis, especially when the test results show no significant motility dysfunction in patients. Some foreign researches showed that HRM based on multiple rapid swallows and solid swallows could effectively identify minor motility dysfunction, thus improve the diagnosis rate of esophageal motility disorder. Nevertheless, so far there is still a lack of evidence focusing on HRM based on mulitple water swallows and solid swallows in China.Objective:To compare the differences of HRM based on three test meal, that is 5ml water swallows, multiple water swallows and solid swallows, for assessment of the esophageal dysfunction in different subgroups of GERD patients.Methods:Patients with refractory GERD who underwent HRM in Sir Run Run Shaw Hospital from May 2014 to December 2015 were enrolled. Based on the symptoms, findings by gastroscopy and the results of PH monitoring within 24h, all the patients were assigned to the following three groups:reflux esophagitis (RE) group, non-erosive reflux disease (NERD) group and symptom-reflux non-association group. The differences of HRM based on three methods, including 5 ml water swallows with 50ml drink,200ml water drink and 150g solid test meal, were compared in the assessment of the esophageal mobility. The esophageal motility disorders,5ml water swallows: according to the Chicago classification of esophageal motility v3.0,200 mL water drink:ineffective contraction after twice multiple water swallows, solid test meal: effectively swallows were less than 50%.Results:Finally,51 patients were enrolled, including 11 RE patients,25 NERD patients and 15 symptom-reflux non-association patients.1. The distal contraction integral (DCI) of RE group was significantly lower than NERD group and symptom-reflux non-association group (P=0.039). The esophageal peristalsis rate of RE group was significantly lower than the other groups (P=0.002).2. The median acidic reflux events and the DeMeester of RE group were significantly higher than those of NERD and symptom-reflux non-association group (p<0.001). The median acidic exposure time of RE group and NERD group were significantly longer than that of symptom-reflux non-association group (p=0.001).3. Esophageal motility disorders were found in 16 of all 51 enrolled patients (31.4%), with ineffective esophageal motility (IEM) in 11 patients (11/16,68.8%), and absent contractility in the rest 5 patients (5/16,31.2%).4. All 51 patients were divided into three groups:no peristalsis group (n=5), invalid esophageal motility group (n=11) and normal function group (n=35). The frequency of reflux in no peristalsis group was significantly higher than that of the latter two groups (P=0.024).5. Based on continuous water swallow with 200ml drink, esophageal motility disorders were found in 28 of all 51 patients (54.9%), which was higher than that of 5 ml water swallows with 50ml drink method, the difference was significant (P=0.017).6. Esophageal motility disorders detection rate was significantly higher using solid test meal (33/51,64.7%) than using conventional method (16/51,31.4%) (p<0.001). The esophageal motility disorders of RE group (90.9%) and NERD group (68%) were significantly higher than that of symptom-reflux non-association group (p=0.024). The effective swallows of RE group in solid test meal was significantly lower than the other two groups (P=0.027).Conclusions:Esophageal motility disorders were common conditions in refractory GERD patients, including fragmented peristalsis, absent contractility and IEM which is the most common type among the three. Esophageal motility disorders detection rate was higher using multiple water swallows (200ml water) and solid test meal (150g rice) than conventional method (10* 5ml water). Further studies are warranted to evaluate the value of them.