Upper esophageal sphincter abnormalities on high-resolution esophageal manometry and treatment response of type II achalasia

doi:10.12998/wjcc.v8.i4.723

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World Journal of Clinical Cases

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Retrospective Study

World J Clin Cases. Feb 26, 2020; 8(4): 723-735
Published online Feb 26, 2020. doi: 10.12998/wjcc.v8.i4.723

Table 1 Demographic characteristics and symptom profiles of subjects based on upper esophageal sphincter parameters

		UES abnormal	UES normal	P value
		(n = 246) [n (%)]	(n = 252) [n (%)]	P value
Gender	Male	120 (48.78)	121 (48.02)	0.864
Gender	Female	126 (51.22)	131 (51.98)	0.864
Age (yr; mean ± SD)		48.05 ± 13.28	43.71 ± 12.18	0.002^b
Dysphagia		12 (4.88)	18 (7.14)	0.314
Heartburn		83 (33.74)	95 (37.70)	0.301
Abdominal pain		62 (25.20)	62 (24.60)	0.826
Chest pain		40 (16.26)	65 (25.79)	0.040^a
Sour regurgitation		138 (56.10)	147 (58.33)	0.357
Ructus		119 (48.37)	131 (51.98)	0.237
Cough		23 (9.35)	14 (5.56)	0.051
Hiccup		18 (7.32)	25 (9.92)	0.460
Globus hystericus		88 (35.77)	99 (39.29)	0.360
Others		106 (43.09)	108 (42.86)	0.590

Level significance is indicated as follows:

^aP < 0.05.

^bP < 0.01.

UES: Upper esophageal sphincter.

Table 2 High-resolution esophageal manometry diagnoses based on the presence of upper esophageal sphincter abnormalities

		UES abnormal	UES normal	P value
		(n = 246) [n (%)]	(n = 252) [n (%)]	P value
Mean DCI (mmHg/s/cm; mean ± SD)		1062.20 ± 873.25	1125.02 ± 887.87	0.281
Failed swallow		106 (45.3)	116 (43.9)	0.761
Panesophageal pressurization		27 (11.5)	26 (9.8)	0.542
Early contraction		36 (15.4)	36 (13.6)	0.580
Rapid contraction		29 (12.4)	28 (10.6)	0.532
Small-break		145 (62)	142 (53.8)	0.066
Large-break		37 (15.8)	49 (18.6)	0.418
Achalasia		13 (5.28)	5 (1.98)	0.049^a
Type I		0 (0.00)	0 (0.00)	-
Type II		13 (5.28)	4 (1.59)	0.023^a
Type III		0 (0.00)	1 (0.40)	0.323
EGJ outflow obstruction		19 (7.72)	27 (10.71)	0.238
Contraction vigor	Failed	16 (6.50)	10 (3.97)	0.096
	Weak	56 (22.76)	43 (17.06)
	Normal	174 (70.73)	199 (78.97)
Distal esophageal spasm		4 (1.63)	2 (0.79)	0.447
Hypercontractile esophagus		0 (0.00)	1 (0.40)	1.000
Ineffective esophageal motility		41 (16.67)	23 (9.13)	0.012^a
Fragmented contraction		23 (9.35)	32 (12.70)	0.233

Level significance is indicated as follows:

^aP < 0.05. HREM: High-resolution esophageal manometry; UES: Upper esophageal sphincter; EGJ: Esophagogastric junction.

Table 3 Upper esophageal sphincter abnormality subtypes based on high-resolution esophageal manometry diagnosis

		UES abnormality subtypes [n (%)]
		Hypertensive alone (n = 27)	Hypotensive alone (n = 42)	Impaired relaxation alone (n = 130)	Hypertensive with impaired relaxation (n = 15)	Hypotensive with impaired relaxation (n = 32)	P value
Gender	Male	15 (55.56)	19 (45.24)	65 (50.00)	7 (46.67)	14 (43.75)	0.889
Gender	Female	12 (44.44)	23 (54.76)	65 (50.00)	8 (53.33)	18 (56.25)	0.889
Age (yr; mean ± SD)		42.81±11.11	50.79±12.43	47.35±13.51	42.53±10.91	54.31±13.49	0.003^b
HREM results
Achalasia		0 (0.00)	1 (2.38)	5 (3.85)	3 (20.00)	3 (9.38)	0.027^a
EGJ outflow obstruction		2 (7.41)	3 (7.14)	10 (7.69)	2 (13.33)	2 (6.25)	0.967
Contraction vigor	Failed	0 (0.00)	4 (9.52)	8 (6.15)	1 (6.67)	3 (9.38)	0.449
	Weak	10 (37.04)	9 (21.43)	29 (22.31)	4 (26.67)	4 (12.50)
	Normal	17 (62.96)	29 (69.05)	93 (71.54)	10 (66.67)	25 (78.13)
Distal esophageal spasm		0 (0.00)	0 (0.00)	3 (2.31)	0 (0.00)	1 (3.23)	0.82
Hypercontractile esophagus		0 (0.00)	0 (0.00)	0 (0.00)	0 (0.00)	0 (0.00)	-
Ineffective esophageal motility		3 (11.11)	9 (21.43)	21 (16.15)	5 (33.33)	3 (9.38)	0.256
Fragmented contraction		3 (11.11)	8 (19.05)	4 (3.08)	1 (6.67)	7 (21.88)	0.001^b
Symptoms
Dysphagia		2 (7.41)	2 (4.76)	5 (3.85)	0 (0.00)	3 (9.38)	0.649
Heartburn		11 (40.74)	16 (38.10)	36 (27.69)	3 (20.00)	17 (53.13)	0.045^a
Abdominal pain		6 (22.22)	12 (28.57)	38 (29.23)	7 (46.67)	9 (28.13)	0.595
Chest pain		2 (7.41)	8 (19.05)	19 (14.62)	2 (13.33)	9 (28.13)	0.183
Sour regurgitation		14 (51.85)	27 (64.29)	72 (55.38)	6 (40.00)	19 (59.38)	0.308
Ructus		16 (59.26)	16 (38.10)	66 (50.77)	8 (53.33)	13 (40.63)	0.088
Cough		3 (11.11)	8 (19.05)	7 (5.38)	1 (6.67)	4 (12.50)	0.383
Hiccup		1 (3.70)	5 (11.90)	11 (8.46)	0 (0.00)	1 (3.23)	0.241
Globus hystericus		6 (22.22)	15 (35.71)	49 (37.69)	5 (33.33)	13 (40.63)	0.238
Others		14 (51.85)	18 (42.86)	52 (40.00)	6 (40.00)	16 (50.00)	0.468

Level significance is indicated as follows:

^aP < 0.05;

^bP < 0.01. UES: Upper esophageal sphincter; HREM: High-resolution esophageal manometry; EGJ: Esophagogastric junction.

Table 4 Comparisons between upper esophageal sphincter abnormal and upper esophageal sphincter normal patients in the lower esophageal sphincter normal group

		UES abnormal (n = 101) [n (%)]	UES normal (n = 109) [n (%)]	P value
Gender	Male	55 (54.46)	56 (51.38)	0.656
Gender	Female	46 (45.54)	53 (48.62)	0.656
Age (yr; mean ± SD)		47.35 ± 13.40	42.82 ± 12.08	0.011^a
HREM results
Mean DCI (mmHg/s/cm; mean ± SD)		938.30 ± 712.85	977.91 ± 728.41	0.691
Failed swallow		44 (43.56)	48 (44.04)	0.945
Panesophageal pressurization		0 (0.00)	0 (0.00)	-
Early contraction		15 (14.85)	15 (13.76)	0.822
Rapid contraction		11 (10.89)	9 (8.26)	0.517
Small-break		69 (68.32)	66 (60.55)	0.242
Large-break		17 (16.83)	24 (22.02)	0.345
Achalasia		0 (0.00)	0 (0.00)	-
EGJ outflow obstruction		0 (0.00)	0 (0.00)	-
Distal esophageal spasm		4 (3.96)	2 (1.83)	0.357
Hypercontractile esophagus		0 (0.00)	0 (0.00)	-
Fragmented contraction		13 (12.87)	21 (19.27)	0.210
Normal contraction		76 (75.25)	79 (72.48)	0.428
Weak contraction		12 (11.88)	9 (8.26)	0.383
Failed contraction		2 (1.98)	3 (2.75)	0.518
Symptoms
Dysphagia		1 (0.99)	9 (8.26)	0.014^a
Heartburn		35 (34.65)	42 (38.53)	0.561
Abdominal pain		30 (29.70)	35 (32.11)	0.707
Chest pain		17 (16.83)	28 (25.69)	0.119
Sour regurgitation		60 (59.41)	61 (55.96)	0.615
Ructus		46 (45.54)	46 (42.20)	0.627
Cough		9 (8.91)	6 (5.50)	0.339
Hiccup		8 (7.92)	11 (10.09)	0.585
Globus hystericus		33 (32.67)	41 (37.61)	0.455
Others		46 (45.54)	47 (43.12)	0.724

Level significance is indicated as follows:

^aP < 0.05. UES: Upper esophageal sphincter; LES: Lower esophageal sphincter; DCI: Distal contraction integral; EGJ: Esophagogastric junction.

Table 5 Comparisons between upper esophageal sphincter abnormal and upper esophageal sphincter normal patients in the lower esophageal sphincter abnormal group

		UES abnormal (n = 133) [n (%)]	UES normal (n = 155) [n (%)]	P value
Gender	Male	57 (42.86)	69 (44.52)	0.778
Gender	Female	76 (57.14)	86 (55.48)	0.778
Age (yr; mean ± SD)		47.74 ± 12.94	44.99 ± 12.20	0.064
HREM results
Mean DCI (mmHg/s/cm; mean ± SD)		1099.10 ± 1019.93	1137.84 ± 1030.13	0.750
Failed swallow		62 (46.62)	68 (43.87)	0.641
Panesophageal pressurization		21 (15.79)	18 (11.61)	0.303
Early contraction		21 (15.79)	21 (13.55)	0.592
Rapid contraction		18 (13.53)	19 (12.26)	0.747
Small-break		76 (57.14)	76 (49.03)	0.170
Large-break		20 (15.04)	25 (16.13)	0.800
Achalasia		13 (9.77)	5 (3.23)	0.022^a
Type I		0 (0.00)	0 (0.00)	-
Type II		13 (9.77)	4 (2.58)	0.010^a
Type III		0 (0.00)	1 (0.65)	0.354
Distal esophageal spasm		1 (0.80)	0 (0.00)	0.280
Hypercontractile esophagus		0 (0.00)	1 (0.65)	0.354
Fragmented contraction		2 (7.14)	22 (14.19)	0.728
Normal contraction		17 (12.78)	119 (76.77)	0.189
Weak contraction		12 (9.02)	9 (5.81)	0.296
Failed contraction		13 (9.77)	12 (7.74)	0.542
Symptoms
Dysphagia		10 (7.52)	9 (5.81)	0.560
Heartburn		42 (31.58)	57 (36.77)	0.380
Abdominal pain		35 (25.32)	41 (26.45)	0.990
Chest pain		23 (14.84)	37 (23.87)	0.171
Sour regurgitation		66 (42.58)	92 (59.35)	0.099
Ructus		63 (40.65)	91 (58.71)	0.055
Cough		13 (8.39)	7 (4.52)	0.081
Hiccup		9 (5.81)	13 (8.39)	0.606
Globus hystericus		49 (31.61)	62 (40.00)	0.584
Others		58 (43.61)	64 (41.29)	0.692

Level significance is indicated as follows:

^aP < 0.05. UES: Upper esophageal sphincter; LES: Lower esophageal sphincter; DCI: Distal contraction integral; EGJ: Esophagogastric junction.

Table 6 Comparisons of high-resolution esophageal manometry results between pretreatment and posttreatment

HREM results	Pretreatment	Posttreatment	P value
UES restP (mmHg; mean ± SD)	68.08 ± 47.90	48.75 ± 27.30	0.674
UES RP (mmHg; mean ± SD)	11.18 ± 7.93	5.35 ± 4.77	0.036^a
LES restP (mmHg; mean ± SD)	41.91± 9.20	26.18 ± 13.08	0.017^a
LES IRP (mmHg; mean ± SD)	38.94 ± 10.28	16.71 ± 5.65	0.012^a
Failed swallow [n (%)]	8 (100.00)	8 (100.00)	1.000
Panesophageal pressurization [n (%)]	8 (100.00)	3 (37.50)	0.038^a
Early contraction [n (%)]	1 (12.50)	1 (12.50)	1.000
Rapid contraction [n (%)]	1 (12.50)	0 (0.00)	0.721
Small-break [n (%)]	0 (0.00)	1 (12.50)	0.721
Large-break [n (%)]	0 (0.00)	1 (12.50)	0.721

Level significance is indicated as follows:

^aP < 0.05. LES: Lower esophageal sphincter; UES: Upper esophageal sphincter; restP: Mean resting pressure; IRP: Integrated relaxation pressure; RP: Residual pressure; HREM: High-resolution esophageal manometry.

Table 7 Mixed analysis of lower esophageal sphincter mean resting pressure, lower esophageal sphincter integrated relaxation pressure, and upper esophageal sphincter residual pressure

Dependent variable	Independent variable	Beta coefficient	SE	P value
LES restP	Intercept	48.30	13.13	0.021^a
	Treatment stage¹	-15.75	3.74	0.004^b
	Gender²	5.64	9.78	0.595
	Age	-0.07	0.38	0.860
LES IRP	Intercept	34.53	5.00	<0.001^c
	Treatment stage	-22.23	3.18	<0.001^c
	Gender	-11.59	2.56	0.011^a
	Age	-0.06	0.10	0.590
UES RP	Intercept	6.04	5.40	0.309
	Treatment stage	-5.82	1.89	0.018^a
	Gender	-6.11	3.65	0.169
	Age	0.04	0.14	0.808

¹Pretreatment stage was used as the reference category.

²Female gender was used as the reference category. Level significance is indicated as follows:

^aP < 0.05;

^bP < 0.01;

^cP < 0.001. Age, sex, and treatment stage were controlled for as between-subject independent variables, considering the random effect of the individual and the effect of repeated measurement before and after treatment. LES: Lower esophageal sphincter; UES: Upper esophageal sphincter; restP: Mean resting pressure; IRP: Integrated relaxation pressure; RP: Residual pressure.

Table 8 Treatment improvement in subjects with type II achalasia based on upper esophageal sphincter dysfunction

Treatment improvement	UES abnormal	UES normal	P value
Favorable	16.67%	100.00%	0.049^a
Poor	83.33%	0.00%

Level significance is indicated as follows:

^a< 0.05.

UES: Upper esophageal sphincter.

Citation: Huang CZ, Huang ZW, Liang HM, Wang ZJ, Guo TT, Chen YP. Upper esophageal sphincter abnormalities on high-resolution esophageal manometry and treatment response of type II achalasia. World J Clin Cases 2020; 8(4): 723-735
URL: https://www.wjgnet.com/2307-8960/full/v8/i4/723.htm
DOI: https://dx.doi.org/10.12998/wjcc.v8.i4.723