A rise in duodenoscope-associated infections, especially in regard to multidrug-resistant organisms, has led to an increase in scrutiny regarding duodenoscope reprocessing. Endoscopic retrograde cholangiopancreatography scopes have a specialized elevator wire channel, allowing more flexible duct cannulation; however, this channel can be difficult to reprocess with standard techniques. Although strict adherence to manufacturer reprocessing protocols remains the primary means of infection prevention, periodic microbiological surveillance is a Food and Drug Administration-recommended practice that the Medical University of South Carolina has implemented to further prevent duodenoscope-associated infections. The Medical University of South Carolina obtains 2 separate cultures from 2 duodenoscopes every 2 months, which undergo standard speciation and sensitivity and are returned to use once negative at 48 hours. The initial results of the Medical University of South Carolina's surveillance cultures are negative for any multidrug-resistant organisms; however, other centers should consider implementing surveillance cultures into their reprocessing practices and closely monitoring for future endoscope infection prevention modalities.

Introduction: Ineffective esophageal motility (IEM) is a common motility disorder, defined as ≥ 50% weak swallows (distal contractile integral (DCI) < 450 mmHg-cm-sec). It is frequently associated with defective bolus transit and may present with dysphagia. Bethanechol, a direct-acting muscarinic receptor agonist, has been shown in pilot studies to increase distal esophageal contraction amplitude in healthy volunteers and patients with IEM. Methods: 9-weeks, randomized, double-blind, placebo-controlled, cross-over study was conducted in patients with severe IEM with a main presenting complaint of dysphagia. Aim of study: Assess the effect of bethanechol (50 mg TID) on dysphagia & manometric changes in patients with IEM. Patients were given placebo or bethanechol for 4 weeks each in a stepwise fashion, then were crossed-over after a 1-week washout. Mayo Dysphagia Questionnaire-30 (MDC-30) and high-resolution impedance manometry (HRIM) obtained at baseline and at the completion of each arm. Adverse effects profile was assessed during the study. Statistical analysis: Non-parametric Friedman’s test was used to compare outcomes for bethanechol, placebo, and baseline. Mean differences and confidence intervals were estimated for the 3 groups<./p> Results: 10 patients completed the study (70% females). Mean age 57.3 years (SD+/-11.9). 1 patient dropped-out because of chest pain while on placebo. 44% of patients developed transient adverse effects that resolved within a week of bethanechol initiation. Median DCI for bethanechol was slightly higher, although it did not reach significance level: 307, Interquartile range (IQR) 39-1306 bethanechol; 208, IQR 72-1171 placebo; 225, IQR 62-495 baseline (P=0.39) (Figure 1). MDC-30 score was slightly lower for bethanechol: 4 (on scale of 0-10), IQR 0-8 bethanechol; 5, IQR 1-8 placebo; 5, IQR 3-10 baseline (P=0.34) (Figure 2).399_A Figure 1 No Caption available.399_B Figure 2 No Caption available.Conclusion: Bethanechol increased distal esophageal contraction amplitude to some extent and decreased sensation of dysphagia at 30-days compared to placebo and more profoundly to baseline. Though, these differences did not reach significance level. Our study’s small sample size likely underestimated the effect of bethanechol. Bethanechol was well-tolerated with absence of serious adverse events, with less than half of patients experienced minor adverse effects that resolved within 1 week of therapy. This pilot study opens the door to explore more the utility of bethanechol in the treatment of IEM.

We read with interest the article regarding endoscope storage time after reprocessing.1Brock A.S. Steed L.L. Freeman J. et al.Endoscope storage time: assessment of microbial colonization up to 21 days after reprocessing.Gastrointest Endosc. 2015; 81: 1150-1154Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar The statement suggested that endoscopes can be stored for as long as 21 days after standard reprocessing with low risk of pathogenic microbial colonization. Only 4 isolates represented potential pathogens (4.2% of 96 sites tested), and all were found in low concentrations. The authors’ results were consistent with those of previous studies that evaluated endoscope contamination using a similar method of sampling.2Gillespie E.E. Kotsanas D. Stuart R.L. Microbiological monitoring of endoscopes: 5-year review.J Gastroenterol Hepatol. 2008; 23: 1069-1074Crossref PubMed Scopus (39) Google Scholar However, the contamination rate is very low compared with those observed in French studies.3Saliou P. Garlantézec R. Baron R. et al.Microbiological investigation of endoscopes at Brest Hospital over a period from 2007 to 2009.Pathol Biol (Paris). 2011; 59: 88-93Crossref PubMed Scopus (11) Google Scholar, 4Gabard A. Borderan G.-C. Chevrie N. et al.Microbiological monitoring of endoscopes: factors determining non-conformities.Hygienes. 2013; 21: 141-144Google Scholar We wonder whether the observed differences could be due to the technique of sampling. The autors used sterile water to irrigate the channels of the endoscopes. In France, the guidelines recommend sampling endoscopes by injecting 120 mL neutralizing pharmacopoeia diluent buffer with sodium thiosulfate into the channels using sterile connectors.5Direction générale de la santé (DGS), CTINILS. Eléments d'assurance qualité en hygiène relatifs au contrôle microbiologique des endoscopes et à la traçabilité en endoscopie [in French]. Available at: http://www.sante.gouv.fr/IMG/pdf/microbio_endoscopes-2.pdf. Accessed March 27, 2015.Google Scholar A two-way channel irrigation is made systematically to improve the efficiency of sampling. The solution is recovered at the distal end of the endoscope, and each collected sample is incubated at 30°C on plate count agar after filtration of 100 mL of the solution on 0.45-μm filters. The aim of this technique of sampling is to pick up biofilms, to neutralize the peracetic acid, and to enable the growth of bacteria, which may be present in the endoscope’s channels. It is possible that the use of sterile water does not achieve the same quality of sampling. Moreover, the amount of fluid analyzed is much lower than that recommended in France. This is why we believe that the level of colonization of the endoscopes may be underestimated by use of the sampling technique described in this study. We believe that further studies should be conducted to confirm these results, which may be very interesting. Endoscope storage time: assessment of microbial colonization up to 21 days after reprocessingGastrointestinal EndoscopyVol. 81Issue 5PreviewInsufficient data exist for how long endoscopes can be stored after reprocessing. Concern about possible microbial colonization has led to various recommendations for reprocessing intervals among institutions, with many as short as 5 days. A significant cost savings could be realized if it can be demonstrated that endoscopes may be stored for as long as 21 days without risk of clinically significant contamination. Full-Text PDF Response:Gastrointestinal EndoscopyVol. 82Issue 3PreviewWe thank Drs Saliou and Baron for their interest in our report and their valuable comments. They highlight the importance of adequate sampling methods to detect endoscope microbial burden and propose an alternate culturing technique to the one used in our study. Specifically, they suggest that neutralizing pharmacopoeia diluent (NPD) with sodium thiosulfate (ST) may be superior to sterile saline solution. Although NPD with ST is recommended in French guidelines,1 sterile saline solution or water-based solutions in the approximate volumes we used are recommended by other major societies, including the European Society for Gastrointestinal Endoscopy,2 the Centers for Disease Control and Infection,3 and the Gastroenterological Society of Australia. Full-Text PDF

GOAL:We hypothesized that sleeping left-side down with the head/torso elevated reduces recumbent gastroesophageal reflux (GER).BACKGROUND:Previous studies show that sleeping with head of bed elevated or on wedge reduces GER and lying left-side down reduces GER versus right-side down and supine. No prior studies have evaluated the potential compounding effects of lying in an inclined position combined with lateral positioning on GER.STUDY:We evaluated a sleep-positioning device (SPD) consisting of an inclined base and body pillow that maintains lateral position while elevating the head/torso. This was a single institution, randomized controlled trial involving 20 healthy volunteers receiving 4 six-hour impedance-pH tests. After placement of reflux probe, subjects returned home, ate standardized meal, and lay down in randomly assigned positions: SPD right-side down (SPD-R), SPD left-side down (SPD-L), standard wedge any position (W), or flat any position (F). A wireless accelerometer documented position during each study. Number of reflux episodes (RE) and esophageal acid exposure (EAE) were calculated over 6 hours.RESULTS:Significantly less EAE occurred during sleeping SPD-L versus sleeping W, SPD-R, and F. The most EAE occurred during sleeping SPD-R despite use of the positioning device. RE were significantly less SPD-L than SPD-R. Patients sleeping SPD-L and SPD-R spent the majority of first 2 hours and greater than half of 6 hours in assigned position. Patients sleeping W and F averaged more time supine than right or left.CONCLUSIONS:The sleep positioning device maintains recumbent position effectively. Lying left-side down, it reduces recumbent esophageal acid exposure.

GOALS:To investigate the frequency of throat clearing (TC) and cough and how often each is associated with a positive symptom index (SI) for reflux.BACKGROUND:Many patients referred to our esophageal laboratory for gastroesophageal reflux disease (GERD) evaluation have "atypical" or "extraesophageal" symptoms.STUDY:We reviewed ambulatory impedance-pH studies of 267 patients referred for evaluation of possible GERD symptoms from January 2012 to December 2013 to evaluate the frequency of cough, TC, and their association with an abnormal number of reflux episodes. Patients with <3 symptom events/24 hours were excluded. Additional analysis was done for those with ≥24 (excessive) symptoms of TC or cough/24 hours. Eighty percent of patients were tested on proton pump inhibitor therapy. SI for either or both symptoms was calculated.RESULTS:A total of 112 of 267 patients (42%) reported both TC and cough on study day, 76/267 (28%) cough without TC and 79/267 (30%) TC without cough. Only 9/112 (8%) had a positive SI, versus 20/76 (26%) and 17/79 (22%) for cough (P=0.0006) and TC (P=0.007), respectively.A total of 136 of 267 patients (51%) reported 3 to 23 TC events/24 hours; 27/136 (20%) had a positive SI. Fifty-five of 267 (27%) had "excessive" TC. Only 7/55 (13%) had a positive SI (P=0.24).A total of 142 of 267 patients (53%) reported 3 to 23 cough events/24 hours; 43/142 (30%) had a positive SI. Forty-six of 267 (17%) had "excessive" cough. Only 6/46 (13%) had a positive SI (P=0.02).Analyses based on ON/OFF therapy, also showed same low rate of positive test and significantly higher number of reflux episodes in those with positive SI.CONCLUSIONS:Although cough and TC are often considered possible GERD symptoms, there is a low probability of objective association. This is even less likely if both symptoms are present. Those patients who reported "excessive" cough are less likely to have a positive SI.

STUDY OBJECTIVE:Because it has been hypothesized that histamine2 receptor antagonists (H2 RAs) might interfere with the action of proton pump inhibitors (PPIs) when the drugs are given concomitantly, we sought to compare the pharmacodynamic effects of simultaneous administration of a PPI and an H2 RA with the effects of each drug administered alone.DESIGN:Prospective, randomized, double-blind, three-way crossover study.SETTING:Esophageal motility laboratory at a large teaching hospital.SUBJECTS:Twenty-one healthy volunteers.INTERVENTION:Subjects were randomized to one of three treatment arms: an H2 RA (ranitidine 300 mg) plus placebo, a PPI (omeprazole 40 mg) plus placebo, or ranitidine 300 mg plus omeprazole 40 mg, all given once/day at 8 a.m., 30 minutes before a standard breakfast, for 1 week. The subjects then received the other two treatments, with each treatment period separated by a 1-week washout period.MEASUREMENTS AND MAIN RESULTS:The primary outcome was length of time that the gastric pH remained higher than 4. Secondary outcomes were median gastric pH higher than 4 and percentage of time that the gastric pH remained higher than 4. On day 7, ambulatory intragastric pH was recorded over an 8-hour period in each treatment arm. The combination of ranitidine and omeprazole resulted in a significantly longer time that the gastric pH remained higher than 4 (median 410.5 min [interquartile range (IQR) 298.5-454.25 min]) versus either omeprazole alone (median 356.7 min [IQR 254.9-419.2 min], p=0.023) or ranitidine alone (134.1 min [IQR 99.9-302.5 min], p<0.0001). Median gastric pH was also significantly higher when omeprazole and ranitidine were given in combination (pH 5.92 [IQR 4.75-6.46]) than either omeprazole alone (pH 4.88 [IQR 4.27-6.11], p=0.001) or ranitidine alone (pH 2.31 [IQR 2.04-5.27], p=0.0003). Likewise, the percentage of time that the gastric pH remained higher than 4 was significantly higher when omeprazole and ranitidine were given in combination (median 85.52%) than either omeprazole alone (74.31%, p=0.027) or ranitidine alone (27.94%, p=0.0002).CONCLUSION:When a PPI and H2 RA were administered concomitantly 30 minutes before breakfast, the H2 RA did not decrease the acid suppressive ability of the PPI; rather, it improved gastric acid control. Thus these results failed to support the initial hypothesis of this study. Further prospective studies are needed to test these findings in patients with gastroesophageal reflux disease as well as those with erosive esophagitis.

Background: Insufficient data exist for how long endoscopes can be stored after reprocessing. Concern about possible microbial colonization has led to various recommendations for reprocessing intervals among institutions, with many as short as 5 days. A significant cost savings could be realized if it can be demonstrated that endoscopes may be stored for as long as 21 days without risk of clinically significant contamination.Objective: To demonstrate whether flexible endoscopes may be stored for as long as 21 days after reprocessing without colonization by pathogenic microbes.Design: Prospective, observational study.Setting: Tertiary care center.Endoscopes: Four duodenoscopes, 4 colonoscopes, and 2 gastroscopes.Intervention: Microbial testing of endoscope channels.Main Outcome Measurements: Culture results at days 0, 7, 14, and 21.Results: There were 33 positive cultures from 28 of the 96 sites tested (29.2% overall contamination rate). Twenty-nine of 33 isolates were typical skin or environmental contaminants, thus clinically insignificant. Four potential pathogens were cultured, including Enterococcus, Candida parapsilosis, alpha-hemolytic Streptococcus, and Aureobasidium pullulans; all were likely clinically insignificant as each was only recovered at 1 time point at 1 site, and all grew in low concentrations. There were no definite pathogenic isolates.Limitations: Single center.Conclusion: Endoscopes can be stored for as long as 21 days after standard reprocessing with a low risk of pathogenic microbial colonization. Extension of reprocessing protocols to 21 days could effect significant cost savings.

Introduction: Hiatal hernias (HH) are frequently diagnosed during upper endoscopy or barium radiography. With the introduction of high resolution manometry (HRM), hiatal hernias can be identified based on finding 2 separate high pressure zones on high resolution topography. The aim of this study is to compare HRM and endoscopic identification of HH. An earlier study done in our institution in 2005 by Agrawal et.al comparing conventional manometry (CM) to endoscopy to identify HH showed that CM had low sensitivity (20%), but high specificity (99%) in identifying HH compared to endoscopy. Methods: A retrospective review was performed of 600 patients who had HRM performed in our laboratory between January 2013 and February 2014. We identified 160 patients (107 females, mean age 54.5 years) who had both HRM and upper endoscopy. The manometric studies were reviewed looking for characteristic double high-pressure zone on high resolution topography separated by 1 cm or more. The endoscopic reports were reviewed for independent identification of HH. Results: Of the 160 patients who had both HRM and EGD, 31 (19%) had HH identified by HRM compared to 29 (18%) by EGD. 12/31 of the manometrically identified HH were also seen on endoscopy. Compared to endoscopy (gold standard), HRM had a sensitivity of 41.4% and a specificity of 87.2% for detecting HH. Conclusion: HRM has low sensitivity and relatively high specificity in identifying HH. Further studies analyzing HRM using better objective criteria need to be identified to more accurately detect HH. Related to our earlier study of CM and EGD, HRM showed higher sensitivity, but lower specificity compared to CM to identify HH. Disclosure - Dr. Donald Castell is a consultant for Sandhill Scientific.

Figure. 1A: 6 hour mean esophageal acid exposure (EAE) by position. SD-L exhibited significantly less EAE than any other position. 1B: 6 hour mean number of reflux episodes (RE) by position. SD-L exhibited significantly less reflux episodes than SD-R. SD-L: Sleeper device left side down. SD-R: Sleeper device right side down. *= p<.05, **=p<.01, ***=p<.001.Purpose: Previous studies show that sleeping with the head of bed elevated or on a wedge reduces gastroesophageal reflux (GER). In addition, while recumbent, left side down reduces GER compared to right side down and supine. We performed a randomized controlled trial evaluating a sleep device (SD) consisting of a two-piece inclined base and body pillow (Medcline, Amenity Health, Inc., San Diego, CA) that maintains a patient in lateral position while elevating the head and torso. We hypothesized that sleeping in a fixed position on the left side with the head and torso elevated would significantly reduce recumbent GER. Methods: This was a single institution, randomized controlled trial involving 20 healthy volunteers, each subject having four impedance-pH tests 6 hours in length. After placement of a reflux probe, subjects returned home and ate a standardized meal (1,350 kcal, 58 g fat). Each subject then lay down in one of 4 randomly assigned positions: SD right-side-down (SD-R), SD left-side-down (SD-L), standard wedge any position (W), and flat any position (F). A wireless position monitor documented position during each study. Number of reflux episodes (RE) and esophageal acid exposure (EAE) was blindly calculated for 6-hour periods. Position monitor data was used to compare assigned position to actual position. Results: Significantly less EAE over 6 hours (hrs) occurred sleeping SD-L compared to sleeping W (mean 0.46% vs. 3.59%, p<.01), SD-R (mean 0.46% vs. 4.59%, p<.001), and F (mean 0.46% v. 3.46%, p<.05). RE over 6 hrs were significantly less SD-L than SD-R (mean 5.55 vs. 13.23, p<.05). Patients assigned to SD-L on average spent 83% of first 2 hrs and 61% of 6 hrs in assigned position. Those assigned to SD-R spent 72% of first 2 hrs and 53% of 6 hrs in assigned position. Over 6 hrs, patients sleeping on W and F averaged significantly more time supine than R or L (p<.05). Conclusion: The sleep device maintains recumbent horizontal position effectively. Lying left-side-down, it dramatically reduces recumbent esophageal acid exposure. As in previous studies, right-side-down position gives the worst results, even with aid of the sleep device. Disclosure - Dr. Erik Person - No financial relationship Janice Freeman, RN - No financial relationship Dr. Chris Rife - No financial relationship Aaron Clark - Employee of Amenity Health, Inc. Dr. Donald Castell - No financial relationship. This research was supported by an industry grant from Amenity Health, Inc.

Purpose: The term “major motility abnormality” (MMA) is useful in our experience to describe manometry studies with features of two co-existing serious motility patterns. This term has not been described previously in the literature. The purposes of our investigation are to describe the term major motility abnormality (MMA) and determine its frequency as noted on impedance-manometry testing in an active manometry lab. Methods: This retrospective study evaluated characteristics of MMA including patient demographics, combination of diagnosis patterns (subtypes), annual frequency, bolus transit, and esophageal body/lower esophageal sphincter pressures. Results: From a total of 4315 esophageal function tests performed during the 9-year period from 1/1/2004 to 12/31/2012, 190 (4.41%) were diagnosed as MMA. Eighty-two of these studies showed dual feature MMAs over this period, resulting in a frequency of <2%. Dual feature MMAs were classifi ed as follows: achalasia / ineffective esophageal motility (IEM); achalasia / distal esophageal spasm (DES); achalasia / systemic sclerosis (SSc); IEM / DES; IEM / SSc; DES / nutcracker; IEM / nutcracker (Figure 1). The median age at MMA diagnosis was 59 (range 19 - 81). Fifty-one percent of these MMA patients were female. Use of the term MMA has increased over the years (Table 1). As the term has evolved, the use of MMA has changed to focus on incorporating two co-existing serious motility abnormalities.FigureTable 1: Annual frequency of MMA (%)Conclusion: The term “major motility abnormality” (MMA) is useful in our experience to describe the rare manometry studies with features of two co-existing motility patterns while informing the referring physician that serious dysmotility exists. MMA with features of achalasia / DES and MMA with features of achalasia / IEM are the most frequently diagnosed abnormalities. The use of MMA may be helpful in the management of these patients.

Purpose: Guidelines for the medical treatment of gastroesophageal reflux disease (GERD) include lifestyle modification, on demand control of symptoms with buffer and antirefluxants, acid control, use of agents to increase motility, and use of agents to decrease lower esophageal sphincter relaxation. The most common approach to the treatment of esophageal reflux disease is acid suppression, however, the mechanisms of esophageal reflux are related to relaxation of the lower esophageal sphincter and other motility factors. This study aims to determine if there is a correlation between the percentage time of intragastric pH < 4 and esophageal acid exposure time. Methods: Data from the 24 hour ambulatory pH monitoring from 398 patients on proton pump inhibitor therapy for GERD symptoms were analyzed using ambulatory pH monitoring. PPIs were taken once daily (n=92), twice daily (n=218), or in combination with H2RA (n=88). Data were recorded on the total percentage time of gastric pH less than 4, the total percentage time of esophageal acid exposure, the upright percentage time of gastric pH less than 4 and upright percentage time of esophageal acid exposure, the recumbent percentage time of gastric pH less than 4 and the recumbent time of esophageal acid exposure. pH electrodes were located 5 cm above the lower esophageal sphincter and 10 cm below the lower esophageal sphincter. The data for individual patients was analyzed and plotted for total, recumbent and upright to determine if there was a correlation between gastric acid control and esophageal acid exposure. Results: Results of the analyses of all groups showed that there was a relatively weak (r=0.38, 0.33, 0.34) although significant (p<0.0001) correlation between intragastric pH < 4 and esophageal acid exposure, whether upright, recumbent, or throughout the duration of the testing. Conclusion: The results of this analysis suggest that control of gastric acid as a primary goal for the control of gastroesophageal reflux disease is not sufficient for all patients. The lack of a strong correlation between gastric pH < 4 and esophageal acid exposure underscores the fact that reflux is a multifaceted problem.

Nurses often function as capsule endoscopy “pre-readers” to save physicians' time and potentially increase diagnostic yield. Training pre-readers is time consuming, not standardized, and may not be feasible during regular business hours. A way to evaluate the progress and accuracy of pre-readers is needed to ensure competency. The aim of this study was to introduce a feedback and progress assessment tool for training novice capsule endoscopy pre-readers. We created a 1-page form with listings of potential findings for each segment of the examination. Findings could be circled or written in. The trainee reviewed capsule studies and filled out the form on each of 220 patients. The physician reviewers subsequently critiqued the data forms, providing feedback regarding missed lesions, overcalls, and overall agreement. Our trainee achieved consistent agreement with the physician reviewers, after reading 80 studies. In conclusion, a simple, 1-page standardized data sheet can be used to facilitate training of novice capsule pre-readers without significant time commitment from the supervising physician. Future studies may validate this resource-efficient instrument as a training and assessment tool for nurses, physicians, and other practitioners learning capsule endoscopy.

Background: To date, the exact mechanism and etiology of achlasia remains unknown.Previous studies of possible inflammatory cell mediated mechanisms have largely been histological studies.Goldblum et al demonstrated lymphocyte infiltrates around myenteric ganglion cells in achalasia esophagomyotomy specimens.Clarke et al used immunohistochemistry to classify these myenteric inflammatory cells as Th-1 lymphocytes, and noted that they remained present throughout the disease course.Kilic et al used immunohistochemistry to demonstrate increased expression of TNF-α in esophageal tissue in achalasia specimens compared to controls.Purpose: The purpose of this study was to classify the immunological infiltrate in achalasia in order to better understand the disease mechanism and etiology.We specifically sought to determine if the concentrations of inflammatory biomarkers (TNFα receptor, IL-6, IFN-γ, IL-12, and IL-4) were elevated in the sera of achalasia patients compared to healthy controls.Methods: Serum from 19 patients seen in the esophageal motility clinic with an established diagnosis of achalasia were analyzed.Exclusion criteria included previously diagnosed malignancy, autoimmune condition, immunodeficiency disorder, and current treatment with steroids or immune modulating drugs.Serum samples were also obtained from 19 age and gender matched healthy volunteers.TNF-α receptor, IL-6, IL-10, IFN-γ, IL-12, and IL-4 levels were assayed via SearchLight multiplex ELISA (Pierce Endogen).ArrayVision™ software was used to calculate the concentrations.Data from the achalasia patients and healthy volunteers were analyzed blindly using a two tailed Mann-Whitney test.Results: The characteristics of the patient group (mean age 62, 50% female) and the volunteer group (mean age 60, 45% female) were similar.There were statistically significant elevations in levels of IL-12 (p= .031)and TNF-α receptor (p=.026) in the achalasia group compared to the controls.There was also a trend toward elevations in IL-6 levels in the achalasia group, but this difference did not reach statistical significance (p=.053).The other biomarkers were either undetectable in both groups or did not show any significant differences.Conclusion: Our study supports the theory that achalasia is an immunologically mediated process that involves both macrophage and Th1 cytotoxic Tcells.These results are consistent with prior histological studies that demonstrated a persistent immune response in achalasia that does not resolve over time.Our study suggests that the inflammatory response is systemic and not limited to local esophageal tissue.

BACKGROUND:Distal oesophageal spasm is a rare and under-investigated motility abnormality. Recent studies indicate effective bolus transit in varying percentages of distal oesophageal spasm patients. AIM:Explore functional aspects including contraction onset velocity and contraction amplitude cut-off values for simultaneous contractions to predict complete bolus transit. METHODS:We re-examined data from 107 impedance-manometry recordings with a diagnosis of distal oesophageal spasm. Receiver operating characteristic analysis was conducted, regarding effects of onset velocity on bolus transit taking into account distal oesophageal amplitude and correcting for intra-individual repeated measures. RESULTS:Mean area under the receiver operating characteristic curve for saline and viscous swallows were 0.84±0.05 and 0.84±0.04, respectively. Velocity criteria of >30 cm/s when distal oesophageal amplitude>100 mmHg and 8 cm/s when distal oesophageal amplitude<100 mmHg for saline and 32cm/s when distal oesophageal amplitude>100 mmHg and >7 cm/s when distal oesophageal amplitude<100 mmHg for viscous had a sensitivity of 75% and specificity of 80% to identify complete bolus transit. Using these criteria, final diagnosis changed in 44.9% of patients. Abnormal bolus transit was observed in 50.9% of newly diagnosed distal oesophageal spasm patients versus 7.5% of patients classified as normal. Distal oesophageal spasm patients with distal oesophageal amplitude>100 mmHg suffered twice as often from chest pain than those with distal oesophageal amplitude<100 mmHg. CONCLUSION:The proposed velocity cut-offs for diagnosing distal oesophageal spasm improve the ability to identify patients with spasm and abnormal bolus transit.