Esophageal Symptoms in Postural Orthostatic Tachycardia Syndrome: A Retrospective Analysis of Esophageal Manometry Data From an Academic Medical Center

Introduction: Postural orthostatic tachycardia syndrome (POTS) is associated with gastrointestinal (GI) and esophageal dysmotility. Our group has previously reported on abnormalities seen on high-resolution esophageal manometry (HREM) in this population. Herein, we aim to identify significant trends in esophageal manometry findings in patients with a diagnosis of POTS vs controls who have undergone HREM. Methods: Retrospective data analysis of patients aged 18 or older diagnosed with POTS who underwent outpatient esophageal manometries between March 2012 – November 2022. Patients with prior esophageal surgery or active opioid use were excluded from the study. Control subjects met the same exclusion criteria and were selected in a consecutive case-controlled fashion. The Chicago Classification v3.0 and v4.0 were used to categorize esophageal motility disorders based on HREM. Statistical significance was calculated using Fisher’s Exact Test for Count Data. Results: Ninety-two of the 124 (74.2%) patients with POTS who underwent esophageal manometry met inclusion criteria. Dysphagia was the most common indication for HREM testing among POTS patients. Presence of hypotensive lower esophageal sphincter (LES) pressure (29.3%) was more common in POTS patients compared to controls (12.3%, P = 0.011). POTS patients had increased prevalence of ineffective esophageal motility or weak peristalsis (28.3%) vs controls (16.3%, P = 0.076), reaching near significance. Controls had a higher prevalence of achalasia (9.78% vs 1.1% in POTS patients, P = 0.018) and EGJ pressure separation (38.0% vs 6.52% in POTS patients, P < 0.0001). The control group neared significance on distal esophageal spasm (DES, 7.61% vs 1.1% in POTS patients, P = 0.064) (Table 1). Conclusion: This study corroborates a higher prevalence of hypotensive LES in patients with POTS, which was also reported in our previous study.3 We also found weaker peristalsis in these patients. In conjunction, this likely reflects autonomic dysfunction and signals these patients are at higher risk of ineffective motility. The higher prevalence of EGD pressure separation and achalasia in controls can likely be attributed to age, as POTS tends to occur in young females.4 These results provide objective evidence of esophageal dysfunction in POTS patients and underscore the importance of using HREM to evaluate GI symptoms and provide effective treatment and symptom management. Table 1. - Chicago Classification by High Resolution Esophageal Manometry (HREM) in a group with a diagnosis of postural orthostatic tachycardia syndrome (POTS) versus a control group without a diagnosis of POTS POTS (n = 92) Control group (n = 92) POTS Control P-value* Abnormal Normal Abnormal Normal % Abnormal % Abnormal Findings 42 50 43 49 45.6522% 0% 1 Achalasia 1 91 9 83 1.087% 9.78% 0.0182 Esophagogastric outflow obstruction 6 86 13 79 6.52% 14.13% 0.1445 Distal esophageal spasm (DES) 1 91 7 85 1.09% 7.61% 0.0644 Hypercontractile or Jackhammer esophagus 0 92 3 89 0% 3.26% 0.2459 Absent contractility 3 89 2 90 3.26% 2.17% 1 Fragmented peristalsis 1 91 2 90 1.09% 2.17% 1 Ineffective esophageal motility (IEM, weak peristalsis) 26 66 15 77 28.26% 16.30% 0.0757 Hypertensive lower esophageal sphincter (EGJ) pressure 6 86 6 86 6.52% 6.52% 1 Hypotensive lower esophageal sphincter (EGJ) pressure 27 65 12 80 29.35% 13.04% 0.0109 Scleroderma esophagus 0 92 3 89 0% 3.26% 0.2459 Nonspecific abnormalities 11 81 5 87 11.96% 5.43% 0.1896 EGJ Pressure Separation (Hiatal hernia) 6 86 35 57 6.52% 38.04% < 0.00001 *Statistically significant P<0.05.