CLINICAL AND PSYCHOLOGICAL CHARACTERISTICS OF PATIENTS WITH GLOBUS

Background: Elevated IBP segregates dysphagic patients with structural processes at the EGJ from those with a normal upper endoscopy (EGD) despite normal IRP on esophageal HRM.This is a validation study evaluating the utility of IBP in predicting EGJ abnormalities among consecutive symptomatic patients undergoing esophageal HRM.Methods: Adult patients with esophageal symptoms who completed validated symptom questionnaires, and underwent EGD and HRM over a 1 year period were identified.Exclusions consisted of prior foregut surgery, and incomplete or inadequate HRM studies.EGD reports were scrutinized for structural processes (strictures, webs rings, hiatus hernia), while symptom questionnaires assessed for esophageal dysphagia.HRM studies were analyzed, and IBP, IRP, EGJ morphology, EGJ contractile integral (EGJ-CI) and esophageal body metrics were recorded; multiple rapid swallows (MRS) were analyzed when available.Univariate and multivariate analyses were performed to assess the clinical value of IBP in predicting structural processes at the EGJ, in comparison to similarly analyzed HRM studies from achalasia (positive controls) and healthy subjects (negative controls).Results: Over the study period, 36 patients (60.2±2.8 yr, 61.1% F) fulfilled study criteria for structural EGJ processes.Comparison groups consisted of 30 patients with normal EGD (49.8±2.6 yr, 76.7% F), 19 achalasia patients (61.9±3.0 yr, 47.3% F) and 21 asymptomatic healthy controls (27.6±0.6 yr, 52.4% F).Except in achalasia (where mean IRP and EGJ-CI were elevated, p≤0.001 for each comparison), esophageal body metrics, mean IRP and EGJ-CI were within the normal range in all other groups (Table ).Higher mean IBP values were seen with structural EGJ processes and achalasia, compared to patients with normal EGD and healthy controls (p <0.01 for each comparison).There were no differences in IBP between normal EGD and healthy controls (p=0.2),and between types of structural lesions (p=0.7).MRS sequences were available for analysis in 33 patients with structural lesions, 29 with normal EGD, and 21 controls.Although IRP values were similar, IBP remained higher during MRS with structural processes compared to normal EGD (p=0.048) and normal controls (p<0.01).On symptom analysis, 64% with structural processes reported dysphagia to either solids or liquids, compared to 85% with achalasia (p=0.09) and 50% with normal endoscopy (p=0.01).When IBP was elevated, 53% with structural processes reported dysphagia; corresponding proportions were 20% with normal endoscopy and 100% with achalasia (p=0.001across groups).Conclusions: Elevated IBP predicts the presence of structural EGJ processes in consecutive patients even when IRP is normal, serving as a marker for pressure compartmentalization. Symptom analysis indicates prediction of dysphagia with elevated IBP is not perfect.Table : Comparison of high resolution manometry metrics between study cohorts * p<0.05 compared to all other groups ** p<0.0001 compared to no structural abnormalities † p<0.0001 compared to all other groups