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HIGH-RESOLUTION MANOMETRY EGJ METRICS AS PREDICTORS OF DISTAL ESOPHAGEAL ACID EXPOSURE
Arianna Vittori
*1,2, Andrés R. Latorre-Rodríguez
1,3, Andrew Keogan
1,4, Sumeet K. Mittal
1,41Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ; 2University of Padua, School of Medicine, Padova, Italy; 3Universidad del Rosario. Escuela de Medicina y Ciencias de la Salud, Bogotá D.C., Colombia; 4Creighton University School of Medicine, Phoenix, AZ
Background: The current reference standards for diagnosing gastroesophageal reflux disease (GERD) are pH monitoring and endoscopy. However, the utility of other tests, such as high-resolution manometry (HRM), has been explored for predicting distal esophageal acid exposure due to their ability to assess esophagogastric junction (EGJ) function and morphology. This study aimed to evaluate the correlations between routinely assessed EGJ parameters and distal esophageal acid exposure, as measured by 24-hour multichannel intraluminal impedance-pH (MII/pH) monitoring, in patients with suspected GERD.
Methods: After IRB approval, we conducted a cross-sectional study to estimate the correlations between HRM-derived EGJ metrics and acid exposure time. Data were queried from a prospectively maintained database of patients who underwent HRM and MII/pH testing for GERD symptoms between February 2018 and October 2024. Exclusions included patients with prior foregut interventions, diagnoses of distal esophageal spasm, hypercontractile esophagus, EGJ outflow disorders, or hiatal hernias >5 cm, and those with MII/pH recordings <18 hours. Continuous data were assessed for normality, and correlations between HRM metrics and the DeMeester score (DMS) were analyzed using Spearman's rank correlation. Categorical data were evaluated using appropriate nonparametric tests.
Results: A total of 84 patients met the inclusion criteria (58 women [69%]; median age, 61 [49.5–69.5] years; median BMI, 27.2 [23.6–31.9] kg/m
2). The distal contractile integral (DCI) was weakly negatively correlated with the DMS (r = -0.24, 95% CI: -0.46 to -0.03, p < 0.05). Most quantitative parameters (e.g., lower esophageal sphincter [LES] overall and abdominal length, LES pressure, EGJ contractile integral [EGJCI], LES pressure index [LESPI], integrated relaxation pressure [IRP], and thoracoabdominal pressure gradient) were not correlated with acid exposure. Notably, patients with a pressure inversion point (PIP) located above the LES exhibited lower median DMS than those with a PIP below the LES (14.4 [4.5–28.5] vs. 56.7 [25.3–81.4], p < 0.05). Additionally, conventional type III (8/9, 88.9%) and Akimoto type C morphologies (11/14, 78.6%) were more frequently associated with pathological DMS than type II (4/9, 44.4%) and type B (1/4, 25%) morphologies.
Conclusions: The EGJ morphology appears to be the only routinely assessed manometric parameter that may independently predict distal esophageal acid exposure and pathological reflux. Furthermore, the position of the PIP relative to the LES is a critical component of morphological assessment; hence, incorporating the physiological EGJ (Akimoto) classification into HRM analysis may aid in the development of diagnostic algorithms for GERD, potentially reducing the reliance on more invasive testing.
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