Taher Omari

Background: Dysphagia and reflux are frequently experienced by individuals with hiatus hernia (HH), but the underlying mechanisms are not fully defined in radiological or manometric studies. This study explores the impact of HH on propulsive esophageal peristalsis and investigates the biomechanical underpinnings of HH‐concurrent–related dysphagia in affected individuals.Methods: High‐resolution manometry with impedance (HRM‐I) studies compared the biomechanics of 195 gastroesophageal reflux disease (GERD) patients (excluding large HH and motility disorders) and 20 normal healthy volunteers. Assessments included dysphagia severity, esophageal pH monitoring, and HRM‐I with 5‐mL liquid and viscous swallows. Bolus distension pressures during bolus transport and esophageal emptying parameters were assessed in conjunction with standard pressure topography metrics. Data grouped by EGJ morphology type were analyzed by a mixed‐effects statistical model.Key Results: Patients with unequivocal HH exhibited altered bolus transport through the mid‐distal esophageal body, indicated by increased intrabolus distension pressure during bolus transport (p < 0.01 for liquid and viscous swallows) and shorter bolus flow time through the EGJ (p ≤ 0.005 for liquid and viscous swallows). Increased HH size during swallows also correlated with increased intrabolus distension pressure (liquid r 0.243, p < 0.001) and shorter EGJ flow time (liquid r − 0.191, p < 0.005). Patients with confirmed GERD without HH showed a different pattern of altered bolus transport in the more proximal esophagus.Conclusion: In the presence of a HH, esophageal biomechanics are altered, with elevated bolus distension pressure revealing resistance to bolus transport occurring in the mid‐lower esophageal body for liquid and viscous boluses, contributing to dysphagia symptoms.

Introduction: The Leuven Consensus provides a classification scheme for the diagnosis of pharyngeal and upper esophageal sphincter (UES) motor disorders using metrics derived from pharyngeal high‐resolution manometry‐impedance (P‐HRM‐I). Methods: Twenty‐six experts with broad multidisciplinary backgrounds contributed their knowledge and experience to this initiative via a formal deliberative Delphi process. Guidance on a swallow assessment protocol as well as diagnostic criteria for UES dysfunction and pharyngeal contractile dysfunction is provided. Results: For UES dysfunction, the stepwise evaluation of UES and intrabolus pressure metrics under increasing bolus volume and/or viscosity conditions is used to confirm failure of manometric relaxation and opening of the UES region. For pharyngeal contractile dysfunction, the evaluation of contractile metrics is used to define pharyngeal hypocontractility or hypercontractility. Conclusion: These recommendations complement routine instrumental investigations and provide a standardized process, criteria, and nomenclature for P‐HRM‐I assessment of patients reporting symptoms of oropharyngeal dysphagia.

Objectives: Esophageal atresia (EA) is a significant congenital anomaly, with most survivors experiencing esophageal dysmotility. Currently, there is no reliable way to predict which patients will develop significant, life‐threatening dysmotility. Using high‐resolution impedance manometry (HRIM), this study aimed to characterize the common pressure topography patterns in children with repaired EA.Methods: This prospective longitudinal cohort study focused on children (<18 years) with repaired EA. Utilizing HRIM, esophageal motility patterns were studied. Repeat manometric assessments were performed in a selected group.Results: Seventy‐five patients with EA (M:F = 43:32, median age 15 months [3 months to 17 years]) completed 133 HRIM studies. The majority (54 out of 75, 85.3%) had EA with distal tracheo‐esophageal fistula. Thirty‐five out of 75 (46.7%) underwent one study, 24 out of 75 (32.0%) two studies, 14 out of 75 (18.7%) three studies, and 2 out of 75 (2.7%) four studies. Seventy‐two patients had analyzable studies. Three common motility patterns were demonstrated: (1) aperistalsis (26 out of 72, 36.1%); (2) distal esophageal contraction (25 out of 72, 34.7%); and (3) pressurization (6 out of 72, 8.3%). A minority demonstrated combination patterns, including aperistalsis with weak distal contraction (10 out of 72, 13.9%) and aperistalsis with pressurization (2 out of 72, 2.8%). Contraction was normal in 3 out of 72 (4.2%). At repeat assessment, the dominant motility pattern persisted in 26 out of 38 (68.4%) of the second studies and 9 out of 15 (60.0%) of the third studies.Conclusion: Utilizing HRIM in children with repaired EA, we have demonstrated objective, distinct, and reproducible motility patterns. In this cohort, the majority of motility patterns were maintained longitudinally, and dysphagia scores remained unchanged, even after dilatation.

Introduction: Fluid thickeners used in the management of oropharyngeal dysphagia exhibit non‐Newtonian shear‐thinning rheology, impacting their viscosity during deglutition. This study investigated how the rheological properties of thickened fluids affect pharyngeal swallowing parameters in patients with oropharyngeal motor disorders diagnosed by pharyngeal high‐resolution manometry impedance (P‐HRM‐I).Methods: Seventy‐two patients (18–89 years) referred for P‐HRM‐I were diagnostically assessed with a 10 mL thin bolus. In 57 of the patients, 10 mL swallows of two moderately thick formulations—xanthan gum (XG) and sodium carboxymethylcellulose gum (CMC)—were also tested. The XG and CMC fluids had equivalent empirical thickness but different viscosity at pharyngeal phase shear rates: XG 87 mPa.s (83–91) versus CMC mean 157 mPa.s (148–164) at 300 s⁻¹. Standard metrics of pharyngeal and upper esophageal sphincter (UES) function were derived from P‐HRM‐I recordings and analyzed to characterize patients into one of four disorder subtypes: (i) No Disorder, (ii) UES Disorder, (iii) Pharyngeal Disorder, and (iv) Combination UES/Pharyngeal Disorder. Impedance recordings also assessed pharyngeal bolus transit.Results: Patients with a Combination UES/Pharyngeal Disorder were most likely to have abnormal bolus transit (82%, p < 0.001). Increasing bolus viscosity significantly influenced UES residual pressure, UES opening area, and post‐swallow residue. Patients with UES Disorder exhibited pronounced increases in UES residual pressure with CMC compared to XG. Pharyngeal contractility was unaffected by viscosity changes. Post‐swallow residue increased with CMC, particularly in patients with a Combination Disorder. Case‐by‐case analysis revealed individual variability in response to the different viscosities.Conclusion: The rheological properties of thickened fluids significantly affect swallowing function, with these effects dependent upon the disorder subtype.

Background: The shear rheology of ingested fluids influences their pharyngo‐esophageal transit during deglutition. Thus, swallowed fluids elicit differing physiological responses due to their shear‐thinning profile.Methods: Two hydrocolloid fluids, xanthan gum (XG) and sodium carboxymethylcellulose gum (CMC), were compared in 10 healthy adults (mean age 39 years). Manometry swallowing assessments were performed using an 8‐French catheter. Swallows were analyzed using the Swallow Gateway web application (www.swallowgateway.com). Grouped data were analyzed by a mixed statistical model. The coefficient of determination (r²) assessed the relationship between measures and bolus viscosity (SI units, mPa.s) at shear rates of 1—1000 s⁻¹.Key Results: Rheology confirmed that the thickened fluids had similar viscosities at 50 s⁻¹ shear rate (XG IDDSI Level‐1, 2, and 3 respectively, 74.3, 161.2, and 399.6 mPa.s vs. CMC Level‐1, 2, and 3 respectively 78.0, 176.5, and 429.2 mPa.s). However, at 300 s⁻¹ shear, CMC‐thickened fluids exhibited approximately double the viscosity (XG Level‐1, 2, and 3 respectively 19.5, 34.4, and 84.8 mPa.s vs. CMC Level‐1, 2, and 3 respectively, 41.3, 80.8, and 160.2 mPa.s). In vivo swallows of CMC, when compared to XG, showed evidence of greater flow resistance, such as increased intrabolus pressure (p < 0.01) and UES Integrated Relaxation Pressure (UESIRP, p < 0.01) and shorter UES Relaxation Time (p < 0.05) and Bolus Presence Time (p < 0.001). The apparent fluid viscosity (mPa.s) correlated most significantly with increasing UESIRP (r² 0.69 at 50 s⁻¹ and r² 0.97 at 300 s⁻¹, p < 0.05).Conclusion: Fluids with divergent shear viscosities demonstrated differences in pharyngeal function. These physiological responses were linked to the shear viscosity and not the IDDSI level.

Mucosal impedance is a marker of esophageal mucosal integrity and a novel technique for assessing esophageal function and pathology. This article highlights its development and clinical application for gastroesophageal reflux disease (GERD), Barrett’s esophagus, and eosinophilic esophagitis. A narrative review of key publications describing the development and use of mucosal impedance in clinical practice was conducted. A low mean nocturnal baseline impedance (MNBI) has been shown to be an independent predictor of response to anti-reflux therapy. MNBI predicts medication-responsive heartburn better than distal esophageal acid exposure time. Patients with equivocal evidence of GERD using conventional methods, with a low MNBI, had an improvement in symptoms following the initiation of PPI therapy compared to those with a normal MNBI. A similar trend was seen in a post fundoplication cohort. Strong clinical utility for the use of mucosal impedance in assessing eosinophilic esophagitis has been repeatedly demonstrated; however, there is minimal direction for application in Barrett’s esophagus. The authors conclude that mucosal impedance has potential clinical utility for the assessment and diagnosis of GERD, particularly when conventional investigations have yielded equivocal results.

Background and Aims: Accurate assessment of patient‐reported oropharyngeal dysphagia (OPD) is essential to guide appropriate management and evaluate response. The Sydney Swallow Questionnaire (SSQ) is a paper‐based 17‐item inventory developed and validated to objectively detect risk of OPD. An easy‐to‐use electronic version with digital output has significant potential in streamlining patient assessment. This study aims to develop and validate an electronic version of the SSQ (eSSQ) against the original paper version.Method: The English‐based paper SSQ was adapted on the online REDcap (Research Electronic Data Capture) platform to be accessible on computer and mobile devices. Patients with OPD and asymptomatic controls completed both electronic and paper versions in randomized order. Patients with stable symptoms then repeated the eSSQ after ≥14 days for test–retest reliability. Paper‐based and eSSQs were also collected from an independent cohort for external validation. Agreement of total scores between both versions and eSSQ test–retest reliability were calculated using two‐way mixed‐effects intra‐class correlation coefficient (ICC).Results: 47 dysphagic patients, 32 controls, and 31 patients from an external validation cohort were recruited. The most common underlying etiology was head and neck cancer. Mean eSSQ total score was 789 in dysphagic patients, and 68 in controls. eSSQ had excellent agreement with paper SSQ in total scores among all participants, with ICC 0.97 (95% CI [0.93, 0.98]) in controls, 0.97 (95% CI [0.94, 0.98]) in dysphagic patients and 0.96 (95% CI [0.92, 0.98]) in validation cohort. Test–retest reliability was also excellent (ICC 0.96, 95% CI [0.90, 0.98]).Conclusion: The newly developed eSSQ shows excellent agreement with the paper version and test–retest reliability. Future applications of its use may allow for more efficient and accessible patient assessment.

Background: The herbal preparation, STW5‐II, improves upper gastrointestinal symptoms, including abdominal fullness, early satiation, and epigastric pain, in patients with functional dyspepsia, and in preclinical models decreases fundic tone and increases antral contractility. The effects of STW5‐II on esophago‐gastric junction pressure, proximal gastric tone and antropyloroduodenal pressures, disturbances of which may contribute to symptoms associated with disorders of gut–brain interaction, including functional dyspepsia, in humans, have, hitherto, not been evaluated.Methods: STW5‐II or placebo (matched for color, aroma, and alcohol content) were each administered orally, at the recommended dose (20 drops), to healthy male and female volunteers (age: 27 ± 1 years) in a double‐blind, randomized fashion, on two separate occasions, separated by 3–7 days, to evaluate effects on (i) esophago‐gastric junction pressures following a standardized meal using solid‐state high‐resolution manometry (part 1, n = 16), (ii) proximal gastric volume using a barostat (part 2, n = 16), and (iii) antropyloroduodenal pressures assessed by high‐resolution manometry (part 3, n = 18), for 120 min (part 1) or 180 min (parts 2, 3).Key Results: STW5‐II increased maximum intrabag volume (ml; STW5‐II: 340 ± 38, placebo: 251 ± 30; p = 0.007) and intrabag volume between t = 120 and 180 min (p = 0.011), and the motility index of antral pressure waves between t = 60 and 120 min (p = 0.032), but had no effect on esophago‐gastric junction, pyloric, or duodenal pressures.Conclusions & Inferences: STW5‐II has marked region‐specific effects on gastric motility in humans, which may contribute to its therapeutic efficacy in functional dyspepsia.

It is crucial to consider the possible influence of anesthetic agents on esophageal function testing. Dexmedetomidine has been shown to affect primary peristalsis during esophageal manometry. In the two case reports presented by Toaz et al., secondary peristalsis during FLIP panometry was also affected. This may be attributed to an alternate pharmacodynamic effect, with a transient direct α2‐mediated effect on esophageal smooth muscle, associated with a high plasma concentration following bolus injection, prior to the onset of sympathetic inhibition.