Subtipos manométricos de motilidade inefetiva do esôfago.


Subtipos manométricos de motilidade inefetiva do esôfago.
Clinical and Translational Gastroenterology 2017; 8: e78; Doi:10.1038/ctg.2017.4.

Neste trabalho é avaliada a motilidade ineficaz do esôfago com apresentação com alternância (contrações presentes alternadas com falhas) e falhas persistentes. A apresentação de falhas persistentes é mais comum em homens mais idosos, em pacientes com doença do refluxo mais intensa e que não respondem bem ao tratamento com inibidores da bomba de prótons. O conhecimento do tipo de motilidade ineficaz do esôfago apresentada pelo paciente tem implicações nos sintomas e no tratamento.

Manometric Subtypes of Ineffective Esophageal Motility. Mirjam Hiestand, Ala’ Abdel Jalil, Donald O. Castell

OBJECTIVES: Ineffective esophageal motility (IEM) is characterized by well-defined manometric criteria. However, much variation exists within the diagnosis: Some patients exhibit exactly the required five weak swallows to make the diagnosis. Others show consistently ineffective swallows with total absence of any normal swallow. “We hypothesize” there are two different manometric
subtypes of IEM; IEM Alternans (IEM-A) and IEM Persistens (IEM-P). METHODS: A total of 231 IEM patients were identified by high-resolution manometry (HRM). IEM defined by distal contractile integral (DCI) of 450 mm Hg/s/cm in ≥ 50% of test swallows. Abnormal reflux study was defined by excess total number of reflux episodes, abnormal esophageal acid exposure, or positive symptom association. RESULTS: A total of 195 (84%) patients had IEM-A and 36 (16%) had IEM-P. A striking gender difference with 34% of IEM-A being males compared to 53% of IEM-P. (P=0.03). Mean age of IEM-P (59.6 years+/ −13.1) was greater than IEM-A (55.5 years+/ −13.6) (P=0.04). Mean lower esophageal sphincter (LES) resting pressure was significantly lower in IEM-P (20.8 mm Hg+/− 1.4) than IEM-A (29 mm Hg+/− 1.2) (P=0.002). There was no difference in LES-integrated relaxation pressure (IRP), bolus transit, or manometric presence of hiatal hernia between the two groups. Out of 146, 89 (61%) patients had abnormal reflux study. Esophageal acid exposure in upright position was significantly higher in IEM-P than IEM-A (3.5 vs. 1.7%, P=0.04). Poor gastric acid control on proton pump inhibitor (PPI) was more prevalent among IEM-P patients (58%) than IEM-A (27%) (P=0.007). In subgroup analysis of 41 IEM patients with dysphagia, DCI for liquid swallows was significantly lower in IEM-P (111+/− 142 mm Hg/s/cm) compared to IEM-A (421+/− 502 mm Hg/s/cm) (P=0.04), lower mean LES resting

pressure in IEM-P (16.6+/− 9 mm Hg) than IEM-A (31.7+/− 18 mm Hg) (P=0.01). CONCLUSIONS: There are two distinct manometric IEM subtypes; IEM-P with an older male predominance, more advanced reflux disease, weaker LES, and worse response to PPI; likely a more advanced manifestation than IEM-A. However, the question if there are different etiologies underlying the two subtypes remains to be answered.