Improved Assessment of Bolus Clearance in Patients With Achalasia Using High-Resolution Impedance Manometry

Dustin A. Carlson*, Claire A. Beveridge, Zhiyue Lin, Michelle Balla, Dyanna Gregory, Michael Tye, Katherine Ritter, Peter J. Kahrilas, John E. Pandolfino

*Corresponding author for this work

Research output: Contribution to journalArticle

7 Scopus citations


Background & Aims: Esophageal retention is typically evaluated by timed-barium esophagram in patients treated for achalasia. Esophageal bolus clearance can also be evaluated using high-resolution impedance manometry. We evaluated the associations of conventional and novel high-resolution impedance manometry metrics, esophagram, and patient-reported outcomes (PROs) in achalasia. Methods: We performed a prospective study of 70 patients with achalasia (age, 20–81 y; 30 women) treated by pneumatic dilation or myotomy who underwent follow-up evaluations from April 2013 through December 2015 (median, 12 mo after treatment; range, 3–183 mo). Patients were assessed using timed-barium esophagrams, high-resolution impedance manometry, and PROs, determined from Eckardt scores (the primary outcome) and the brief esophageal dysphagia questionnaire. Barium column height was measured from esophagrams taken 5 minutes after ingestion of barium (200 mL). Impedance-manometry was analyzed for bolus transit (dichotomized) and with a customized MATLAB program (The MathWorks, Inc, Natick, MA) to calculate the esophageal impedance integral (EII) ratio. Results: Optimal cut points to identify a good PRO (defined as Eckardt score of ≤3) were esophagram barium column height of 3 cm (identified patients with a good PRO with 63% sensitivity and 75% specificity) and an EII ratio of 0.41 (identified patients with a good PRO with 83% sensitivity and 75% specificity). Complete bolus transit identified patients with a good PRO with 28% sensitivity and 75% specificity. Of the 25 patients who met these cut points for both esophagram barium column height and EII ratio, 23 (92%) had a good PRO. Of the 17 patients who met neither cut point, 14 (82%) had a poor PRO (Eckardt score above 3). Conclusions: In a prospective study of 70 patients with achalasia, we found EII ratio identified patients with good PROs with higher levels of sensitivity (same specificity) than timed-barium esophagram or impedance-manometry bolus transit assessments. The EII ratio should be added to achalasia outcome evaluations that involve high-resolution impedance manometry as an independent measure and to complement timed-barium esophagram.

Original languageEnglish (US)
Pages (from-to)672-680.e1
JournalClinical Gastroenterology and Hepatology
Issue number5
StatePublished - May 2018


  • Esophagram
  • Outcome
  • Swallow
  • Symptom

ASJC Scopus subject areas

  • Hepatology
  • Gastroenterology

Fingerprint Dive into the research topics of 'Improved Assessment of Bolus Clearance in Patients With Achalasia Using High-Resolution Impedance Manometry'. Together they form a unique fingerprint.

  • Cite this