Manometric profile of patients presented with dysphagia – A hospital-based descriptive study

INTRODUCTION

The western hemisphere seems to have done groundbreaking research on dysphagia. However, the east lags behind. In India, studies on dysphagia and its medical and surgical interventions are still said to be in their infancy.^[1] The prevalence of dysphagia was reported as 16–22% in individuals above 50 years of age.^[2] Another recent population-based study showed that the prevalence of dysphagia was about 17% in the adult population.^[3] Aetiology of dysphagia ranges from benign to malignant conditions.^[3]

Dysphagia, difficulty in swallowing is the common presentation of the patients suffering from Achalasia Cardia. Achalasia cardia is an oesophageal motor disorder which results from ineffective peristalsis and incomplete or absent lower oesophageal sphincter (LES) relaxation.^[4] High-resolution oesophageal manometry (HREM) is the gold standard technique available for diagnosing and staging Achalasia cardia.^[5] This technique assesses the upper oesophageal pressures, oesophageal contractility and peristalsis pattern, resting LES pressure and lower oesophageal relaxation. HREM is a rapid and direct method which avoids the use of contrast materials and exposure to radiation.

Treatment options available to reduce LES resting pressure include botulinum toxin injection, oral nitrates, disruption of muscular bundles of LES by laparoscopic myotomy, pneumatic dilation (PD) and peroral endoscopic myotomy (POEM).^[6] In pneumatic dilation, a pneumatic balloon is passed through the LES, which disrupts the muscle fibres and reduces the pressure of the LES.^[7] POEM is a relatively recent and minimally invasive procedure in which muscles in the lower part of the oesophagus, around the sphincter and in the upper stomach, are resected on endoscopic guidance.^[4] In this present study, we aimed to assess the manometric profile of patients who presented with dysphagia in a tertiary care hospital in South India and also compare the outcomes of the interventional procedures POEM and Pneumatic Dilation in achalasia cardia patients.

MATERIALS AND METHODS

This hospital-based descriptive study was conducted in a tertiary care hospital after obtaining the Institutional Ethical Committee clearance. Patients, both males and females, presented with complaints of dysphagia for both solids and liquids belonging to the age group between 18 and 65 years who reported to the gastroenterology department were included in the study. Patients with pregnancy, oesophageal or fundic varices, previous gastric/oesophageal surgery, oesophageal cancer, collagen disease, chronic alcoholics, uncontrolled diabetes, acute and advanced cardiopulmonary disease, systemic sclerosis and uncontrolled thyroid disorders were excluded from the study.

One hundred and twenty-nine patients fulfilled the inclusion and exclusion criteria, which were included in this study after general and systemic clinical examinations of patients were subjected to HREM. The HREM procedure was performed after overnight fasting. The procedure was performed after getting informed consent and explaining the procedure to the patient.

RESULTS

Descriptive statistics

One hundred and twenty-nine patients with dysphagia between the age group of 18–65 years participated in the study.

Among them, 44% had increased IRP. The average basal LES pressure was 28.81 mmHg (28.81 ± 19.82) and the average IRP was 17.08 mmHg (17.08 mmHg ± 14.04) [Table 1].

Table 1: Average basal LES pressure and IRP.

	Mean (mmHg)±Std. Deviation
Basal LES Pressure	28.81±19.82
IRP	17.0814.04

LES: Lower oesophageal pressure, IRP: Integrated relaxation pressure

With respect to motility, out of the total 129 patients, 71% had simultaneous/failed or absent peristalsis, 23% had propagative motility, 5% had ineffective (or fragmented) contractions, and the remaining 1% had premature contractions [Figure 1].

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Figure 1:

Motility pattern.

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Based on the Chicago classification, out of the 129 patients presented with dysphagia, 70 were found to have achalasia cardia. Of the 70 patients, 75% were managed medically, and 25% underwent procedural intervention [Figure 2].

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Figure 2:

Intervention type.

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Comparative statistics

Out of the 32 patients who underwent intervention, peroral oesophageal endoscopic myotomy (POEM) was performed in 15 patients and pneumatic balloon dilatation (PD) was done in 17 patients [Figure 3]. The efficacy of the intervention was assessed based on the comparison between the pre- and post-procedural values, paired sample test (Wilcoxon signed-rank test) was used for statistical analysis.

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Figure 3:

Descriptive bar diagram of patients who underwent Peroral Esophageal Myotomy and Pneumatic Dilatation Procedures. POEM: Peroral oesophageal myotomy, PD: Pneumatic dilatation.

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When the pre (30.51 ± 20.01 mmHg) and post (19.94 ± 11.71 mmHg) resting lower oesophageal pressures of the patients who underwent pneumatic balloon dilatation were compared, no significant difference was found. Similarly, the pre (22.38 ± 14.21 mmHg) and post (13.19 ± 10.76 mmHg) IRP values were compared, and no statistical significance was found.

In the patients who underwent POEM, the pre (33.84 ± 30.14 mmHg) and post (19.72 ± 13.92 mmHg) LES pressures were compared, and there was no statistical significance.

However, the post-IRP value (8.393 ± 7.779 mmHg) was significantly decreased when compared to the pre-IRP value (20.35 ± 11.34 mmHg) [Table 2].

Table 2: Before and after intervention.

Motility pattern	Pre/post	Mean (mmHg)±Std. Deviation	Significance
PD: LES	Pre-procedure	30.511±20.012	0.084
	Post-procedure	19.941±11.716
PD: IRP	Pre-procedure	22.382±14.212	0.017
	Post-procedure	13.194±10.763
POEM: LES	Pre-procedure	33.840±30.148	0.125
	Post-procedure	19.72613.922
POEM: IRP	Pre-procedure	20.353±11.345	0.005
	Post-procedure	8.3937.779

LES: Lower oesophageal pressure, IRP: Integrated relaxation pressure, PD: Pneumatic dilatation, POEM: Peroral oesophageal myotomy

DISCUSSION

HREM is claimed to be the diagnostic tool for diagnosing common motor disorders of the oesophagus such as achalasia cardia, diffuse oesophageal spasm, nutcracker oesophagus and hypertensive LES.^[8] Results of the randomised trial conducted by Roman et al. revealed that oesophageal motility disorders and achalasia were more frequently diagnosed with HREM than with conventional manometry.^[9] Misra et al., in their study, elaborated that manometric features of achalasia cardia include absent peristalsis in the body of the oesophagus with incomplete relaxation of the LES.^[10] Increased or normal resting LES pressure (LES <30 mmHg) and IRP >15 mmHg is conclusive of achalasia cardia.^[11]

In our study, we observed 44% of patients had increased that IRP % and, 36.4% had increased basal LES pressure and 77% had ineffective motility which included simultaneous peristalsis, fragmented and premature contractions. In 2017, Goyal et al., in their study conducted among patients with dysphasia, reported that 43.8% had ineffective oesophageal motility, 26.3% had achalasia cardia, 6.9% had a distal oesophageal spasm and 19.4% had normal manometric findings.^[12]

In our study, 32 patients underwent interventional procedures, peroral oesophageal endoscopic myotomy (POEM) was performed in 15 patients and pneumatic balloon dilatation was done in 17 patients. In a study conducted among achalasia cardia patients who underwent pneumatic dilatation, the success rate observed was found to be ranging from 75% to 91% after 6 months and 73–81% after 12 months.^[13,14] In patients those who underwent PD, the efficacy wanes with time and complications reported include perforation (2%) and heartburn (15–35%).^[15,16] In our study, an achalasia patient who underwent pneumatic balloon dilatation reported to have decreased in resting LES pressure and IRP at the end of 1 month follow-up.

POEM was reported to be a safe and effective treatment option compared to PD and Hellers myotomy, with a success rate of 82–100%.^[17,18] In the present study, 15 patients who underwent POEM, the post-IRP values were found to be significantly reduced. In line with our present study, authors reported a significant decrease in the LES pressure and IRP from 33 ± 1.7 and 30 ± 1.4 mmHg to 14 ± 1.2 and 13 ± 1.6 mmHg, respectively, over a period 6 months in study conducted among 2373 patients with achalasia cardia.^[19] A study done among 40 achalasia patients who failed to show positive outcomes prior to pneumatic dilation showed favourable results after POEM with an Eckardt score 3 or less.^[20] Results of the study conducted among 21 patients also showed similar results.^[21] In a follow-up study, both technical (97%) and clinical success (93%) were observed in about 551 achalasia patients who underwent POEM procedure.^[22]

We wish to extend our present study with larger sample size, and also, we wish to include the symptomatic profile, Eckardt score and the follow-up of clinical and manometric profiles over a year of the achalasia cardia patients who underwent interventional procedures. Moreover, we wish to conduct multicentric studies in future to determine manometric profiles of normal healthy volunteers to add significance to the normative values held for the Indian population.

CONCLUSION

Our study results showed that 44% of patients presented with dysphagia were diagnosed with achalasia cardia. POEM procedure was found to be more effective when compared to pneumatic dilatation.