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Comparison of the 2cc Bolus and the 200cc Bolus Multiple Rapid Swallow Technique in the Evaluation of Patients With Dysphagia
Shunsuke Akimoto*, Se Ryung Yamamoto, Harit Kapoor, Tommy H. Lee, Sumeet K. Mittal
Creighton University Medical Center, Omaha, NE
High-resolution manometry (HRM) is considered ‘gold standard' for esophageal motility evaluation. The provocative Multiple Rapid Swallow technique (MRS) has been recently shown to augment functional characterization of the esophageal transit. The bolus volumes and intervals used in various studies vary and need comparison and standardization. The study aims to evaluate the test-characteristics of the 2cc bolus MRS and 200cc bolus MRS.
Methods
All patients undergoing HRM evaluation between June 2014 to October 2014 were also administered the MRS. In these patients, we selected the subjects who could perform both methods, 2cc bolus MRS and 200cc bolus MRS. 2cc method required four swallows of 2ml water boluses, four seconds apart whereas 200cc method required swallowing 200ml water continuously. The parameters measured were Post-deglutitory Inhibition (PDI) and the success of Rebound Esophageal Contraction (REC) using the 30mmHg isobaric contour. PDI was considered complete unless a contraction measuring > 3cm was identified during MRS, wherein it was considered incomplete. REC was considered failed when it had either no muscle contraction, when the intersegmental trough was >3cm or when smooth muscle contraction was interrupted for >3cm. We compared the sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of 2cc method and 200cc method in the detection of dysphagia. Patients with known achalasia or previous foregut surgery were excluded.
Results
Sixty-five patients underwent HRM during the study period, of which 45 met the inclusion criteria. The mean age of the group was 56.8 years with 19 (42.2%) males. Twenty-eight (62.2%) patients had dysphagia. On HRM, the mean Integrated relaxation pressures (IRP) was 9.4 and mean Distal contractile integral (DCI) was 2642. On comparing the manometric characteristics of the REC, the 200cc method had significantly lower IRP (0.8 vs. 3.3; p=0.0217) and lower DCI (1005 vs. 2129; p=0.0005) compared to 2cc method. REC failure was observed much more commonly when using the 200cc method (36, 80% vs 24, 53.3%; p=0.0076). Incomplete PDI was relatively more frequent when testing with the 2cc method (15, 33.3% vs 13, 28.9%; p=0.6507). Although, the Se of 200cc method was relatively higher (78.6% vs. 64.3%), the Sp, PPV and NPV was much lower than the 2cc method (Sp; 17.7% vs. 64.7%, PPV; 61.1% vs. 66.7%, NPV; 33.3% vs. 52.4%). The 2cc method had considerably better test characteristics than the conventional HRM alone (Se; 39.3%, Sp; 64.7%, PPV; 64.7%, NPV; 39.3%).
Conclusion
Very low values of IRP and DCI along with higher failure of REC when using the 200cc method, suggests profound suppression of rebound peristalsis affecting test parameters. The 2cc MRS method is more functionally acceptable with test characteristics substantially superior to conventional HRM.
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