Esophageal Dysmotility and the Utility of Barium Swallow: An Opaque Diagnosis

Research Article

Ann Surg Perioper Care. 2017; 2(1): 1021.

Esophageal Dysmotility and the Utility of Barium Swallow: An Opaque Diagnosis

Aronova A¹*, Finnerty BM¹*, Moore M¹, Afaneh C¹, Turkmany K¹, Ciecierega T², Crawford C³, Fahey TJ¹ and Zarnegar R¹

¹Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, USA

²Division of Pediatric Gastroenterology, Department of Pediatrics, New York Presbyterian Hospital, Weill Cornell Medical College, New York, USA

³Division of Gastroenterology and Hepatology, Department of Medicine, New York Presbyterian Hospital, Weill Cornell Medical College, New York, USA

*Corresponding author: Anna Aronova, Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, USA

Brendan M. Finnerty, Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, USA

Received: January 18, 2017; Accepted: February 09, 2017; Published: February 10, 2017

Abstract

Background: The gold standard for diagnosis of esophageal dysmotility is high-resolution manometry (HRM); however, barium swallow studies are still routinely incorporated in the diagnostic algorithm by clinicians. We aim to assess the sensitivity of barium swallow to diagnose esophageal dysmotility using HRM for comparison.

Methods: We retrospectively reviewed 100 consecutive patients evaluated for esophageal dysmotility by both barium swallow and HRM. Dysmotility on barium swallow was graded as mild, moderate or severe. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated, including an achalasia subset analysis.

Results: Compared to HRM, barium swallow had an overall sensitivity, specificity, NPV, and PPV of 88%, 35%, 80%, and 51%, respectively, for detecting esophageal dysmotility. In achalasia patients (N=17), it detected dysmotility with 100% sensitivity and 30% specificity. Excluding achalasia patients, barium swallow had 81% sensitivity and 35% specificity; in other words, 65% of patients with normal HRM were misdiagnosed with dysmotility on barium swallow. For patients who exhibited normal, mild, moderate, and severe dysmotility as diagnosed on barium swallow, the concordance rates compared with HRM were 80%, 22%, 27%, and 89%, respectively.

Conclusion: Compared to the gold standard using high-resolution manometry, barium swallow accurately rules out patients with achalasia and is reliable in evaluating patients with severe dysmotility. However, it is a poor testing modality for diagnosis of esophageal dysmotility in patients without achalasia, especially in mild or moderate disease. As such, careful consideration of the diagnosis of esophageal dysmotility should be taken when using this technique.

Keywords: Barium swallow; Manometry; Esophageal dysmotility; Achalasia

Introduction

Esophageal motility disorders are a compilation of conditions resulting from inappropriate function of the lower esophageal sphincter (LES) and associated dysfunction of the peristaltic activity of the esophagus. Motor disorders of the esophagus may have ineffective or lost peristaltic function as in achalasia, or high or uncoordinated esophageal muscle contractions as in diffuse esophageal spasm and nutcracker esophagus, which may lead to failure of propagation of food into the stomach [1]. Given the variety of physiologic disturbances that occur in esophageal motility disorders, patients present with varied clinical complaints. Most commonly, patients complain of dysphagia and heartburn, although retrosternal chest pain, weight loss, regurgitation, and respiratory symptoms from aspiration may also occur [2–4].

In the diagnostic algorithm for dysphagia, upper endoscopy, barium esophagram (barium swallow), pH monitoring, and esophageal function tests (such as manometry) are indicated. While each testing modality offers unique contributions for the diagnosis of esophageal disorders, high resolution manometry (HRM) is typically considered the gold standard for diagnosing esophageal dysmotility [5–8]. In 2008, an international consortium created the Chicago Classification scheme for primary esophageal motility disorders based on manometry metrics [9]. After several iterations, the most recent 2012 criteria now include four major diagnostic groups: achalasia, esophagogastric junction outflow obstruction, motility disorders not observed in normal subjects (distal esophageal spasm, hyper contractile esophagus, and absent peristalsis), and statistically defined peristaltic abnormalities (weak peristalsis, frequent failed peristalsis, rapid contractions with normal latency and hypertensive peristalsis) [10]. Despite its superiority for the diagnosis of esophageal motility disease, some centers do not have access to HRM. Therefore, many practitioners rely on barium swallow studies to assess for the presence of esophageal dysmotility particularly for screening studies as they are inexpensive and widely available. Radiologist interpretation typically includes a description of esophageal anatomy as well as the presence and degree of any dysmotility.

Given the variable use of barium swallow studies and HRM in the diagnosis of esophageal dysmotility disorders, we aimed to assess the reliability of barium swallow studies compared to the gold standard high resolution manometry in diagnosing esophageal dysmotility. By discerning the accuracy of these diagnostic techniques, we sought to better identify which patients are accurately diagnosed with a motility disorder based on barium swallow findings, and those who require further diagnostic work-up. Based on radiographic characterization, we aim to prove only severe dysmotility is of clinical significance.

Materials and Methods

After Institutional Review Board approval, we retrospectively reviewed 198 patients who presented with symptoms suggestive of esophageal dysmotility and subsequently underwent HRM or barium swallow at the New York Presbyterian Hospital - Weill Cornell Medical College from January 2011 to July 2013. Included were patients who had both studies available for review. Exclusion criteria were patients who had undergone esophageal orgastric surgical procedures (e.g. Nissen fundoplication, Heller myotomy, bariatric surgery, etc), or who did not have adequate data for analysis. Demographic information was collected including age, sex, presenting symptoms including the Eckardt score [11], and proton-pump inhibitor (PPI) usage. Esophageal motility data were collected from HRM reports, as were barium swallow interpretations from radiologist reports. Barium swallow studies were performed according to standard protocol, [12] and dysmotility was graded as mild, moderate or severe by attending radiologists at our institution. At our institution, a radiologist may consider one tertiary contraction over the course of an exam in the supine position as mild versus multiple contractions in the upright position leading to delayed emptying from “to and fro” motion as moderate. In contrast, severe dysmoltility would be unopposed contractile stimulation and aperistalsis.

High resolution manometry (HRM) was also performed following standard protocol [13]. It was completed and analyzed by a single physician at our institution (RZ). Results were reported as abnormal when there was evidence of esophageal dysmotility based on the reader’s interpretation of the study results consistent with the Chicago Classification criteria, including diagnoses of achalasia, isolated hypertensive LES, esophageal spasm, and dysmotility nototherwise- specified. Specific parameters of the manometry reports that were analyzed in this study included lower esophageal sphincter (LES) length (cm), presence of hiatal hernia, basal LES pressure (mmHg), residual LES pressure (mmHg), swallow characterization (peristaltic vs. simultaneous vs. failed), double- and triple- peaked waves (% of total number of swallows), wave amplitude (mmHg) at 3, 7, and 11 cm above the LES, intrabolus pressure (mmHg), and distal contractile integral (mmHg-cm-s).

Statistical analyses were performed using STATA, release 13 (StataCorp, College Station, TX). For comparison of categorical variables, Fisher’s exact and Chi square tests were used for =5 and >5 observations, respectively. Student’s t-test or Mann–Whitney U test was used to analyze continuous parametric and nonparametric variables, respectively. For all analyses, a two-tailed p-value of <0.05 was considered significant; independent predictors with p-value of <0.1 on univariate analysis were included in multivariate analysis (logistic regression with odds ratios).

Results

One-hundred patients met inclusion (criteria consisting of 56 females and 44 males with a mean age of 52 ± 16years. Symptomatically, most patients presented with dysphagia (59%), followed by heartburn (57%), weight loss (48%), regurgitation (43%), and retrosternal chest pain (26%). The median Eckardt score for the entire cohort was 2 (range, 0-10). Eighty-one percent of the cohort was taking proton-pump inhibitors upon initial presentation. Using HRM as the gold-standard for diagnosis, 57% of the cohort had normal motility findings. Of the 43 patients with dysmotility on HRM, the final diagnoses were achalasia (40%), dysmotility nototherwise- specified (42%), esophageal spasm (16%), and isolated hypertensive LES (2%) Table 1. Summarizes patient characteristics between those with achalasia, other dysmotility, and normal motility as diagnosed on HRM.