SummaryHigh-resolution esophageal manometry [HRM] has become the gold standard for the evaluation of esophageal motility disorders. It is unclear whether there are HRM differences in diagnostic outcome based on regional or geographic distribution. The diagnostic outcome of HRM in a diverse geographical population of Mexico was compared and determined if there is variability in diagnostic results among referral centers. Consecutive patients referred for HRM during 2016–2020 were included. Four major referral centers in Mexico participated in the study: northeastern, southeastern, and central (Mexico City, two centers). All studies were interpreted by experienced investigators using Chicago Classification 3 and the same technology. A total of 2293 consecutive patients were included. More abnormal studies were found in the center (61.3%) versus south (45.8%) or north (45.2%) P < 0.001. Higher prevalence of achalasia was noted in the south (21.5%) versus center (12.4%) versus north (9.5%) P < 0.001. Hypercontractile disorders were more common in the north (11.0%) versus the south (5.2%) or the center (3.6%) P.001. A higher frequency of weak peristalsis occurred in the center (76.8%) versus the north (74.2%) or the south (69.2%) P < 0.033. Gastroesophageal junction obstruction was diagnosed in (7.2%) in the center versus the (5.3%) in the north and (4.2%) in the south p.141 (ns). This is the first study to address the diagnostic outcome of HRM in diverse geographical regions of Mexico. We identified several significant diagnostic differences across geographical centers. Our study provides the basis for further analysis of the causes contributing to these differences.

Abstract High resolution esophageal manometry (HREM) has been in use for about a decade. However, there is no available information regarding geographical or regional differences in diagnostic outcome. Aim Characterize the indications, demographics and diagnostic outcome of HREM in a diverse population of Mexico. Methods Data was collected from four major referral centers representing diverse geographical areas of Mexico: central—Mexico City (two centers, years 2016-2020), south (Veracruz, years 2015-2020) and north (Monterrey, years 2013—2020). All consecutive cases referred for HREM were entered into a data base and analyzed using Chicago 3 classification. Data was evaluated using chi-square to compare frequencies among groups. Results 2,932 patients included: Central n = 877(29.9), North n = 1003(34.2), South n = 1052(35.9). Mean age 47.9(11-93), women 1,795(61.2), men 1,137(38.8). Nationwide, the most common indications for testing were: GERD n = 1677(57.2), followed by dysphagia 587(20), atypical GERD 244(8.3), post-operative GERD 230(7.9), chest pain 114(3.9), and post-operative dysphagia 78(2.8). HREM was normal in 1,468(49.9) patients. Table shows the diagnostic distribution among centers: Central-Mexico had more abnormal cases 531(60.5) (p < 0.0.001) vs 407(40.6) North and 532(50.6) South. Achalasia was more commonly diagnosed in the South n = 104(19.5) whereas outlet obstruction 39(967) p < 0.001 and spastic disorders were more common in the North 47(11.8) p = 0.002. Weak peristaltic disorders were more common in Central-Mexico 369(78.8) p < 0.001. Conclusion This study represents the first large comparative multicenter HREM data base project in Mexico. In this cohort, most patients receiving HREM are women and those whose indication was GERD. These findings indicate variable regional geographical distribution of HERM diagnosis. Our study suggests that further investigation into the causes and epidemiological distribution of motility disorders is warranted.

Jackhammer esophagus (JE) is a recently recognized esophageal motility disorder that is characterized by hypercontractile peristalsis. More than 500 cases have been reported in the literature. Among patients referred for esophageal motility disorders, the prevalence of JE ranges from 0.42% to 9%, with most series describing a prevalence of 2% to 4%. Most cases are women (60.5%). The mean reported age of patients with JE is 65.2 years, and patients commonly have dysphagia (62.8%). Reflux symptoms occur in ∼40% of patients, and chest pain affects more than one-third of patients (36.4%). JE is a heterogenous disorder that is associated with several conditions, including obesity, opioid use, lung transplantation, eosinophilic infiltration of the esophagus, neoplasia, and systemic diseases. The cause and pathogenesis remain unknown, but several observations suggest that it is the result of multiple conditions that likely precipitate increased excitation and abnormal inhibition of neuromuscular function. The natural course of JE also is unknown, but progression to achalasia has been observed in a few patients. Treatment is challenging, in part because of the insufficient understanding of the disorder's underlying mechanisms. Various therapeutic modalities have been used, ranging from observation only to pharmacologic and endoscopic interventions (eg, botulinum toxin injection) to peroral endoscopic myotomy. Treatment efficacy remains largely anecdotal and insufficiently studied.

Abstract Ambulatory esophageal reflux monitoring (AEpH) is useful in evaluating persistent or refractory esophageal symptoms despite adequate pharmacologic and/or surgical therapy. There is limited information whether there are geographical or regional differences in the diagnostic outcome of this test. Aim Characterize the diagnostic outcome of AEpH in a diverse population of Mexico. Analyze whether there is regional geographical diagnostic variability. Methods Data was collected from four major referral centers representing diverse geographical areas of Mexico: Mexico City-Central (two centers, years 2016-2020), Veracruz-South (years 2015-2020) and Monterrey-North (years 2013-2020). Consecutive patients undergoing AEpH with persistent GERD symptoms despite PPI therapy and negative upper endoscopy (no erosive disease >C or D LA classification) were entered into a data base and analyzed. Patients were classified as: NERD (acid exposure time (AET > 6.0%); hypersensitive esophagus (normal AET and positive symptom index (SI) or positive symptom association probability [SAP]); functional heartburn (NL AET, neg SI/SAP). Statistics: ANOVA, Chi-square and descriptive methods were used to compare variables among groups. Results 969 cases met inclusion criteria: 311 (32.1%) Central, 430 (44.3%) South, and 228 (23.5%) North. The results are summarized in the table. There were more women 618(63.8%) than men 351(36.2%); p < 0.001 with a mean age 47.7 ± 14.3. Patients were older in Central-Mexico 49.3 ± 13.6 years vs South 47.5 ± 15 and North 46.1 ± 13.6; p = 0.033. Functional heartburn was the most common diagnosis overall and more prevalent in Central-Mexico 171(55%) vs North 97(42.5%) and South 160(37.2%); p < 0.001. NERD was more predominant in the South 171(39.8%) vs North 72(31.6%) and Central-Mexico 98(31.5%); p = 0.029. Hypersensitive esophagus was more frequent in the North 59(25.9%) vs South 99(23%), and Central 42(13.5%); p < 0.001. Conclusion This is the first large data base study to evaluate the outcome of ambulatory esophageal reflux pH testing in Mexico. Our findings indicate a geographical variability of GERD phenotypes and suggest that further investigations are warranted to determine the causes of this distribution.

Introduction and aims: Jackhammer esophagus is a recently identified motility disorder. Experience with the novel pathologic condition has been reported in different studies but there is little information on the subject in Latin America. Our case series conducted in Bogota, Colombia, describes the prevalence of jackhammer esophagus and its demographic, clinical, and manometric characteristics. Materials and methods: A retrospective, observational, cross-sectional study included consecutive patients diagnosed with jackhammer esophagus that were referred for high-resolution esophageal manometry. Their clinical and manometric records were reviewed, and the pertinent information for the present study was collected. Results: Within the study period, 6,445 patients were evaluated with esophageal manometry, 27 of whom were diagnosed with jackhammer esophagus (prevalence of 0.42%). The majority of those patients were women (n = 17, 63%) in the sixth decade of life. The most common symptom was regurgitation (n = 17, 63%), followed by dysphagia (n = 15, 56%). The mean distal contractile integral was 9,384 (5,095-18,546) mm Hg.s.cm. Dysphagia was more common in patients 60 years of age (79%, p < .01) and regurgitation was more frequent in patients < 60 years of age (92%, p < .03). Conclusions: The present study is the first to characterize the prevalence of jackhammer esophagus and its demographic, clinical, and manometric characteristics in Latin American patients. The prevalence of jackhammer esophagus in our study population was considerably lower than that reported in international case series. Our findings suggest that there are important geographic differences in the epidemiology and clinical presentation of jackhammer esophagus, compared with data from other international centers. (C) 2019 Asociacion Mexicana de Gastroenterologa. Published by Masson Doyma Mexico S.A.

Myasthenia gravis (MG) is an autoimmune disease that affects the postsynaptic membrane at the neuromuscular junction. In MG, antibodies bind to acetylcholine receptors inducing muscle weakness. The weakness typically increases with exercise and repetitive muscle use. Improvement of muscular weakness after rest and/or administration of anticholinesterase drugs (edrophonium) are characteristic of MG. We report a patient with unexplained dysphagia, dysphonia, and dysarthria, whose diagnosis was suggested by high-resolution esophageal motility and edrophonium infusion. We highlight the importance of dysphagia as presenting or dominant symptom in MG and review the esophageal motility findings in this rare, but treatable disorder.

Resumen: Introducción y objetivos: «Jackhammer esophagus» (o esófago en «martillo hidráulico» en español), es un trastorno motor esofágico identificado recientemente. Diversos estudios han descrito su experiencia con este novel padecimiento. Sin embargo, no existe información al respecto en Latinoamérica. Nuestro trabajo describe la prevalencia, características demográficas, clínicas y manométricas en una serie de casos con «jackhammer esophagus» en Bogotá, Colombia. Materiales y métodos: Este es un trabajo observacional retrospectivo de corte transversal. Pacientes consecutivos referidos para manometría esofágica de alta resolución diagnosticados con «jackhammer esophagus» fueron considerados para el estudio. Los expedientes clínicos y manométricos de estos enfermos fueron revisados y la información pertinente extraída. Resultados: Durante el periodo de estudio, 6445 pacientes fueron evaluados con manometría esofágica, 27 fueron diagnosticados con «jackhammer esophagus» (prevalencia 0.42%). La mayor parte, fueron mujeres (n = 17,63%) en la sexta década. El síntoma más común fue la regurgitación (n = 17, 63%), seguido por disfagia (n = 15, 56%). El promedio de contracción distal integral observado fue 9,384 (5,095-18,546) mm Hg-s-cm. Disfagia fue más común (79% p< 0.01) en pacientes de > 60 años y regurgitación más frecuente (92%, p < 0.03) en < 60 años. Conclusiones: Este es el primer estudio en caracterizar la prevalencia, hallazgos demográficos, clínicos y manométricos en pacientes con «jackhammer esophagus» en Latinoamérica. En nuestra población, la prevalencia de este trastorno es notablemente más baja que en series internacionales. Nuestros hallazgos sugieren la existencia de importantes diferencias geográficas en la prevalencia y presentación clínica de «jackhammer esophagus» en comparación con datos de otros centros internacionales. Abstract: Introduction and aims: Jackhammer esophagus is a recently identified motility disorder. Experience with the novel pathologic condition has been reported in different studies but there is little information on the subject in Latin America. Our case series conducted in Bogota, Colombia, describes the prevalence of jackhammer esophagus and its demographic, clinical, and manometric characteristics. Materials and methods: A retrospective, observational, cross-sectional study included consecutive patients diagnosed with jackhammer esophagus that were referred for high-resolution esophageal manometry. Their clinical and manometric records were reviewed, and the pertinent information for the present study was collected. Results: Within the study period, 6,445 patients were evaluated with esophageal manometry, 27 of whom were diagnosed with jackhammer esophagus (prevalence of 0.42%). The majority of those patients were women (n = 17, 63%) in the sixth decade of life. The most common symptom was regurgitation (n = 17, 63%), followed by dysphagia (n = 15, 56%). The mean distal contractile integral was 9,384 (5,095-18,546) mmHg·s·cm. Dysphagia was more common in patients > 60 years of age (79%, p < .01) and regurgitation was more frequent in patients < 60 years of age (92%, p < .03). Conclusions: The present study is the first to characterize the prevalence of jackhammer esophagus and its demographic, clinical, and manometric characteristics in Latin American patients. The prevalence of jackhammer esophagus in our study population was considerably lower than that reported in international case series. Our findings suggest that there are important geographic differences in the epidemiology and clinical presentation of jackhammer esophagus, compared with data from other international centers.

Jackhammer esophagus (JE) is a recently recognized esophageal motility disorder that is characterized by hypercontractile peristalsis. More than 500 cases have been reported in the literature. Among patients referred for esophageal motility disorders, the prevalence of JE ranges from 0.42% to 9%, with most series describing a prevalence of 2% to 4%. Most cases are women (60.5%). The mean reported age of patients with JE is 65.2 years, and patients commonly have dysphagia (62.8%). Reflux symptoms occur in ∼40% of patients, and chest pain affects more than one-third of patients (36.4%). JE is a heterogenous disorder that is associated with several conditions, including obesity, opioid use, lung transplantation, eosinophilic infiltration of the esophagus, neoplasia, and systemic diseases. The cause and pathogenesis remain unknown, but several observations suggest that it is the result of multiple conditions that likely precipitate increased excitation and abnormal inhibition of neuromuscular function. The natural course of JE also is unknown, but progression to achalasia has been observed in a few patients. Treatment is challenging, in part because of the insufficient understanding of the disorder’s underlying mechanisms. Various therapeutic modalities have been used, ranging from observation only to pharmacologic and endoscopic interventions (eg, botulinum toxin injection) to peroral endoscopic myotomy. Treatment efficacy remains largely anecdotal and insufficiently studied.

INTRODUCTION:Non-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases. AIM:To present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients. METHODS:Three general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i)definitions, epidemiology, and pathophysiology; (ii)diagnosis, and (iii)treatment. The statements underwent 3rounds of voting, utilizing the Delphi system. The final statements were those that reached >75% agreement, and they were rated utilizing the GRADE system. RESULTS AND CONCLUSIONS:The final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.

High-resolution esophageal manometry (HREM) has become the method of choice for evaluation of esophageal motility disorders. There is a paucity of data with this technique from Hispanic countries. This study aims to characterize the diagnostic outcome of HREM in a large cohort of consecutive patients in Mexico.This study was conducted in Monterrey, Mexico from March 1, 2013 to March 31, 2015. Our diverse study population included patients from a major academic institution and the community. HREM was done applying the Chicago Classification 3. Diagnostic outcome was grouped as weak peristaltic disorders, gastroesophageal junction disorders, and hypertensive/uncoordinated peristalsis.We studied 670 consecutive patients, 57% were women, mean age was 43.8 years. The majority (465 [69%]) were referred for preoperative evaluation of gastroesophageal reflux disease (GERD), 365 (78%) of whom had a normal study. Overall, 193 (29%) patients had abnormal motility, the most common disorder being weak peristalsis (104 [54%]). In patients with dysphagia, the most frequent finding was achalasia (23/46 [50%]).To our knowledge, this is the first study to characterize the diagnostic outcome of HREM in a large cohort of Hispanic patients in Latin America. At our open access center, 69% of patients were referred for preoperative evaluation of GERD, reflecting the popularity of antireflux surgery. This study confirms the high prevalence of weak peristalsis and highlights the importance of addressing its pathophysiology and management. The finding of achalasia in 50% of our patients with dysphagia is consistent with recent reports regarding the rising incidence of this disorder and underscores the need of prompt motility testing in this population.

BACKGROUND & AIMS: Eosinophilic esophagitis (EoE) is assessed endoscopically (endoscopic activity), based on grades of edema, rings, exudates, furrows, and strictures (EREFS). We examined variations in endoscopic assessments of severity, developed and validated 3 EREFS-based scoring systems, and assessed responsiveness of these systems using data from a randomized placebo-controlled trial of patients with EoE. METHODS: For the development set, 5 gastroenterologists reviewed EREFS findings from 266 adults with EoE and provided endoscopist global assessment scores (EndoGA, scale of 0 to 10); variation (Delta EndoGA) was assessed using linear regression. We evaluated simple scores (features given arbitrary values from 0 to 3) and developed 2 scoring systems (adjusted score range, 0-100). We then fitted our linear regression model with mean EndoGA to data from 146 adults recruited in centers in Switzerland and the United States between April 2011 and December 2012. For the validation set, we collected data from 120 separate adults (recruited in centers in Switzerland and the United States between May 2013 and July 2014), assessing regression coefficient-based scores using Bland-Altman method. We assessed the responsiveness of our scoring systems using data from a randomized trial of patients with EoE given fluticasone (n=16) or placebo (n=8). RESULTS: The distribution of EndoGA values differed among endoscopists (mean Delta EndoGA, 2.6 +/- 1.8; range 0-6.6). We developed 2 regression-based scoring systems to assess overall and proximal and distal esophageal findings; variation in endoscopic features accounted for more than 90% of the mean EndoGA variation. In the validation group, differences between mean EndoGA and regression-based scores were small (ranging from -4.70 to 2.03), indicating good agreement. In analyses of data from the randomized trial, the baseline to end of study change in patients given fluticasone was a reduction of 24.3 in simple score (reduction of 4.6 in patients given placebo, P= .052); a reduction of 23.5 in regression-based overall score (reduction of 6.56 in patients given placebo, P= .12), and a reduction of 23.8 (reduction of 8.44 in patients given placebo, P= .11). CONCLUSION: Assessments of endoscopic activity in patients with EoE vary among endoscopists. In an analysis of data from a randomized controlled trial, we found that newly developed scoring systems are no better than simple scoring system in detecting changes in endoscopic activity. These results support the use of a simple scoring system in evaluation of endoscopic activity in patients with EoE.

BACKGROUND & AIMS:Clinical and endoscopic features of eosinophilic esophagitis (EoE) differ between children and adults and among racial backgrounds. We investigated whether there were any associations between race or sex and clinical presentation, endoscopic features, and histologic findings from patients with EoE of various racial backgrounds.METHODS:We performed a retrospective, multicenter, cross-sectional analysis of 793 patients with EoE (476 adults and 317 children; mean age, 26 years; range, 0.1-84 years; 72% male) from clinical registries at 5 tertiary care centers in the United States. EoE was defined per consensus guidelines. Data with predetermined variables were extracted from clinical registries at each participating institution.RESULTS:Of the study cohort, 660 patients were white (83%), 77 were African American (10%), and 56 were of other races (7%). A significantly larger proportion of white persons than African Americans or other races had dysphagia (74%, 56%, and 53%, respectively; P < .001), food impaction (35%, 13%, and 13%, respectively; P < .001), and features of EoE that included rings (46%, 25%, and 18%, respectively; P < .001) or furrows (70%, 58%, and 55%, respectively; P = .012). Males and females had similar clinical presentations, histories of atopy, findings from endoscopy, and histologic characteristics. A higher proportion of males than females had strictures (17% vs 11%; P = .038).CONCLUSIONS:Race, and to a smaller degree sex, are associated with features of EoE. African Americans have different clinical symptoms and fewer endoscopic features of EoE than white persons. EoE should be considered in African Americans even without typical findings.