• endoscopic functional lumen imaging probe
• esophageal motility
• esophagogastric junction contractile integral
• gastroesophageal reflux disease
• high-resolution esophageal manometry

• 52020-2020-0911 Liupanshui Science and Technology Bureau

• Esophageal motility
• Gastroesophageal reflux disease
• High-resolution esophageal manometry

• Humans
• Gastroesophageal Reflux/diagnosis
• Gastroesophageal Reflux/etiology
• Esophagogastric Junction/pathology
• Esophagitis, Peptic
• Gastrectomy/methods
• Manometry/methods
• Gastric Bypass
• Obesity, Morbid/surgery
• Retrospective Studies

Straight leg raise (SLR) can be utilized to evaluate the integrity of the esophagogastric junction during high-resolution manometry (HRM). We aim to assess the value of transient hiatal separation during SLR in symptomatic reflux patients.

Consecutive reflux patients undergoing esophageal HRM and pH monitoring were included. Transient hiatal separation was defined by a ≥ 1 cm separation between the lower esophageal sphincter and crural diaphragm during SLR. We compared esophageal motor patterns and reflux monitoring parameters between patients with normal, transiently abnormal and consistently abnormal esophagogastric junction morphology during SLR.

Of 85 (56.3% female, mean age: 46.7 ± 12.3 years) completed SLR, esophagogastric junction morphology was normal in 31 (36.5%), transient hiatal separation in 19 (22.3%), and consistently hiatal hernia in 35 (41.2%). The values of total acid exposure time (P = 0.016), longest acid reflux episodes (P = 0.024), and DeMeester scores (P = 0.016) were higher in hiatal hernia compared to patients with non-transient hiatal separation, but there were no differences between those with and without transient hiatal separation. Within ineffective esophageal motility, the presence of transient hiatal separation during SLR significantly associated with a higher total acid exposure time (P = 0.014), higher DeMeester scores (P = 0.019), higher total acid reflux events (P = 0.037), and higher longest acid reflux episodes (P = 0.006).

Our work suggests that SLR may have value as a provocative test during HRM, and future outcome studies are warranted to elucidate the clinical relevance of motor abnormalities depicted from SLR.

• Esophageal sphincter
• Hernia
• Leg
• Manometry
• hiatal
• lower

Gastroesophageal reflux disease (GERD) is one of the most commonly encountered digestive diseases in the world, with the prevalence continuing to increase. Many patients are successfully treated with lifestyle modifications and proton pump inhibitor therapy, but a subset of patients require more aggressive intervention for control of their symptoms. Surgical treatment with fundoplication is a viable option for patients with GERD, as it attempts to improve the integrity of the lower esophageal sphincter (LES). While surgery can be as effective as medical treatment, it can also be associated with side effects such as dysphagia, bloating, and abdominal pain. Therefore, a thorough pre-operative assessment is crucial to select appropriate surgical candidates. Newer technologies are becoming increasingly available to help clinicians identify patients with true LES dysfunction, such as pH-impedance studies and high-resolution manometry (HRM). Pre-operative evaluation should be aimed at confirming the diagnosis of GERD, ruling out any major motility disorders, and selecting appropriate surgical candidates. HRM and pH testing are key tests to consider for patients with GERD like symptoms, and the addition of provocative measures such as straight leg raises and multiple rapid swallows to HRM protocol can assess the presence of underlying hiatal hernias and to test a patient’s peristaltic reserve prior to surgery.

• Gastroesophageal reflux disease
• Fundoplication
• High resolution manometry
• pH-impedance
• Anti-reflux surgery
• Pre-operative assessment

• Esophageal pH Monitoring
• Fundoplication
• Gastroesophageal Reflux/diagnosis
• Humans
• Hydrogen-Ion Concentration
• Manometry
• Surgeons

Due to a thicker abdominal wall in some patients, ultrasound artifacts from gastrointestinal gas and surrounding tissues can interfere with routine ultrasound examination, precluding its ability to display or clearly show the structure of a hernial sac (HS) and thereby diminishing diagnostic performance for esophageal hiatal hernia (EHH). Contrast-enhanced ultrasound (CEUS) imaging using an oral agent mixture allows for clear and intuitive identification of an EHH sac and dynamic observation of esophageal reflux.

In this case series, we report three patients with clinically-suspected EHH, including two females and one male with an average age of 67.3 ± 16.4 years. CEUS was administered with an oral agent mixture (microbubble-based SonoVue and gastrointestinal contrast agent) and identified a direct sign of supradiaphragmatic HS (containing the hyperechoic agent) and indirect signs [e.g., widening of esophageal hiatus, hyperechoic mixture agent continuously or intermittently reflux flowing back and forth from the stomach into the supradiaphragmatic HS, and esophagus-gastric echo ring (i.e., the “EG” ring) seen above the diaphragm]. All three cases received a definitive diagnosis of EHH by esophageal manometry and gastroscopy. Two lesions resolved upon drug treatment and one required surgery. The recurrence rate in follow-up was 0%. The data from these cases suggest that the new non-invasive examination method may greatly improve the diagnosis of EHH.

CEUS with the oral agent mixture can facilitate clear and intuitive identification of HS and dynamic observation of esophageal reflux.

• SonoVue
• Oral gastrointestinal contrast agent
• Contrast-enhanced ultrasound
• Gastrointestinal
• Hiatal hernia
• Case report

• acid exposure time
• gastroesophageal reflux disease
• high-resolution manometry
• straight leg raise maneuver