Ineffective Esophageal Motility (IEM) Is a Manometric Disorder Poorly Recognised by Barium Radiography

Introduction: IEM is the most frequently identified esophageal motility disorder in patients referred for motility testing with prevalence of 20-30 %. Dysphagia is common in IEM (25 % of patients), thus, many clinicians prefer to order a barium esophagram (BE) in the evaluation. The definition of weak peristalsis came from concurrent studies of video fluoroscopy and manometry, showing that hypotensive peristalsis is associated with incomplete bolus clearance. Thus, we hypothesize that IEM can be diagnosed with BE beside gold standard manometry. Methods: Aim: To evaluate IEM patients for any radiographic abnormalities (structural or functional) as well as estimate the diagnostic utility of BE in IEM. Methods: Expert radiologist blindly reviewed BE of 53 consecutive IEM patients vs 50 subjects with normal motility, both groups underwent high resolution manometry (HRM) and BE in our institution from 10/1/2015 to 10/1/2017. IEM identified in HRM based on Chicago classification 3.0. In BE, we reported the presence/absence of weak primary peristalsis, tertiary contractions, barium reflux either spontaneous or with provocative testing, and structural abnormalities like hiatal hernia (HH). IEM patients were further sub classified into 2 groups based on the presence/absence of radiographic dysmotility, and we compared distal contractile integral (DCI), distal esophageal amplitudes (DEA), number of weak swallows and presence/absence of dysphagia in both groups. Results: The sensitivity of observing weak peristalsis on BE was 30%, while specificity was 72%. 24/53 (45%) of IEM patients had dysmotility on BE, vs 20/50 (40%) in the control (P = 0.46) (Table 1). BE showed reflux in 29/53 of IEM, vs 25/50 in control (P = 0.6). HH was present in 19/53 IEM vs 15/50 in control (P = 0.5). Comparison of IEM patients with radiographic dysmotility vs those with normal BE is demonstrated in table 2. Conclusion: Our results showed poor sensitivity and modest specificity of BE in IEM. There was no significant difference between IEM and controls regarding presence of dysmotility, barium reflux and HH on BE. Moreover, HRM metrics and dysphagia presence were not significantly different in IEM with and without radiographic signs dysmotility. It is concluded that IEM is a manometric diagnosis made in the appropriate clinical setting, and that the radiographic findings are nonspecific. We believe it should not be recommended as either a screening nor as a confirmatory test for this disorder.383_A Figure 1 No Caption available.383_B Figure 2 No Caption available.