Ravi, Karthik

Abstract Dysphagia is defined as a subjective sensation of difficulty swallowing and can result from oropharyngeal or esophageal etiologies based upon patient symptoms. Dysphagia affects approximately 16% of adults in the general population, with prevalence increasing with age. Esophagogastroduodenuoscopy (EGD) is initially performed to assess for structural abnormalities resulting in esophageal dysphagia. However, if EGD reveals no pathologic abnormalities, high-resolution manometry (HRM) and barium esophagography are performed in order to assess for underlying causes of dysmotility. Esophageal motility disorders (EMDs) are an underrecognized cause of dysphagia and can be characterized by impaired esophageal peristalsis or lower esophageal sphincter dysfunction. High-resolution manometry (HRM) measures key metrics such as integrated relaxation pressure (IRP), which is the deglutitive relaxation across the LES, and metrics of esophageal body peristalsis based on distal contractile integral (DCI) and distal latency (DL). The Chicago Classification version 4 (CCv4.0), published in 2021, provides a standardized classification scheme for differentiating EMDs using metrics from HRM. Additionally, barium esophagography has remained an important adjunctive diagnostic modality, as this may identify strictures, neoplasms, or hiatal hernias, but can also identify major motility disorders such as achalasia and distal esophageal spasm. The combined use of HRM with timed barium esophagram can enhance the diagnostic accuracy of EMDs, particularly when HRM demonstrates inconclusive findings. Therefore, radiologists should be familiar with how imaging findings from barium esophagram integrate with findings noted on HRM. The aim of this review is to highlight the findings of EMDs noted on HRM in conjunction with barium esophagography, thereby illustrating characteristic patterns of primary and secondary EMDs.

Summary Esophageal high-resolution manometry (HRM) is the gold standard for evaluating esophageal motility disorders but can be limited by patient intolerance. With increasing use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) for obesity and type 2 diabetes, delayed gastric emptying raises concerns for HRM feasibility and safety. This study assessed HRM tolerability in patients on GLP-1RAs. We conducted a retrospective case–control study of adult patients who underwent HRM at our tertiary care center between January 2014 and November 2024. Patients actively taking GLP-1RAs during HRM were identified as cases, while an equal number of consecutive eligible patients not on GLP-1RAs served as controls. Patients with established gastrointestinal dysmotility, prior foregut surgery, esophageal mechanical obstruction, large hiatal hernias, malignancy, or recent opioid use were excluded. From a prospective database of 7194 HRM attempts, 83 cases and 83 matched controls were identified. Among 166 patients, 15 (9.0%) had incomplete HRM due to intolerance, with similar rates between GLP-1RA users and controls (10.84% vs. 7.2%, P = 0.59). Predictors of incomplete HRM included younger age (44.9 ± 17.4 vs. 60.4 ± 13.7 years, P < 0.01), globus (P = 0.02), dyspepsia (P = 0.02), and depression (P = 0.04). No aspiration or adverse events occurred in either group. Duration of HRM before abortion was similar between cases and controls. GLP-1RA use was not associated with increased risk of HRM abortion or adverse events, suggesting these medications do not significantly impact HRM feasibility or safety.

ABSTRACTBackgroundAchalasia is associated with an increased risk of esophageal cancer; though reported incidence rates vary widely (0.4% to 9.2%) due to differences in demographics, follow‐up duration, and diagnostic methods. This study evaluates the risk of esophageal cancer and Barrett's esophagus (BE) in achalasia using a large national database and a propensity‐matched control cohort.MethodsAchalasia patients were identified utilizing the TriNetX database based on International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes for diagnostic procedures and lower esophageal sphincter (LES) directed therapies, including Heller myotomy, peroral endoscopic myotomy, and pneumatic dilation. A matched control group of celiac disease patients was used. A 1‐year lead time was applied to exclude secondary malignant achalasia. Outcomes included the incidence of esophageal cancer and BE, with subgroup analysis in patients following therapy.ResultsAmong 7863 achalasia patients (mean age 58.0, 51.9% female), the esophageal cancer risk was significantly higher than control (risk ratio 2.87, 95% CI: 1.56–5.27, p < 0.001). The absolute risk was low, with 40 cases (0.51%) over a mean follow‐up of 3.18 years. BE risk was also higher in achalasia (risk ratio 1.54, 95% CI: 1.24–1.90, p < 0.001), with 220 cases (2.80%). Subgroup analysis revealed no significant difference in BE risk between POEM and Heller myotomy (risk ratio 1.0, 95% CI: 0.42–2.40, p > 0.99).DiscussionThe elevated cancer risk in achalasia over a short follow‐up period warrants reconsideration of current endoscopic surveillance guidelines, despite the low absolute risk of esophageal cancer and BE.

ABSTRACT Background Functional lumen imaging probe (FLIP) utility is established in treatment‐naïve achalasia but less clear following lower esophageal sphincter (LES) directed therapy. Methods Achalasia patients with LES directed therapy across three tertiary care centers between 2017 and 2024 with post‐treatment FLIP and timed barium esophagram (TBE) were retrospectively identified. Reduced esophagogastric junction (EGJ) opening was defined by distensibility index (DI) < 2 mm 2 /mmHg and diameter < 12 mm. Abnormal emptying on TBE was defined as column height ≥ 5 cm at 5 min and/or retained tablet. Eckardt scores ≤ 3 defined clinical response. Key Results The study included 222 patients (46% peroral endoscopic myotomy, 46% laparoscopic Heller myotomy, 8% pneumatic dilation) with a median of 1.4 years to post‐treatment TBE/FLIP. Abnormal emptying on TBE was associated with a narrower median EGJ diameter (13.2 vs. 14.8 mm, p = 0.008), a greater frequency of EGJ diameter < 12 mm (36% vs. 21%, p = 0.012), and a smaller change in EGJ diameter (+4.6 vs. +8.6 mm, p = 0.002). Abnormal emptying on TBE occurred more frequently in patients with EGJ DI < 2 mm 2 /mmHg (8.5% vs. 2.6%, p = 0.052), but was not associated with median EGJ DI (4.5 vs. 5.1 mm 2 /mmHg, p = 0.29) nor median change in EGJ DI (+2.9 vs. +3.9 mm 2 /mmHg, p = 0.25). Patients with reduced EGJ DI or EGJ diameter more often had abnormal TBE (37% vs. 22%, p = 0.012). Only the change in DI (+3.8 vs. +1.5 mm 2 /mmHg, p = 0.012) and diameter (+8.2 vs. +1.6 mm, p = 0.002) on FLIP was associated with a clinical response based on Eckardt ≤ 3. Conclusions and Inferences FLIP following achalasia therapy generally correlates with TBE, although discrepant findings are not uncommon. In particular, FLIP EGJ‐diameter has a strong association with esophageal emptying on TBE. Both TBE and FLIP have limited association with clinical response based on Eckardt, with change in DI and diameter on FLIP most strongly associated. Consequently, FLIP as part of multimodal assessment appears useful in the longitudinal follow‐up of treated achalasia.

ABSTRACTIntroductionEsophageal dysmotility following metabolic bariatric surgery (MBS) may relate to decreased gastric compliance. We investigated high‐resolution esophageal manometry (HRM) and secondary peristalsis assessed by functional lumen imaging probe (FLIP) and their association with intragastric pressure after MBS.MethodsPatients undergoing HRM, FLIP, and barium esophagram (BE) after MBS were included. HRM metrics and proximal intragastric pressure at baseline (IGP baseline), during wet swallow‐induced esophagogastric junction relaxation (IGP EGJ opening), and following wet swallow‐induced esophagogastric junction opening with subsequent closure (IGP post EGJ closure) were measured. Contractile response was assessed during FLIP.ResultsForty patients (26 Roux en Y gastric bypass, 14 sleeve gastrectomy) with FLIP a median of 4 years after MBS, were identified. HRM was normal or consistent with ineffective esophageal motility (IEM) in 33 (82.5%) patients, while the contractile response on FLIP was abnormal (disordered/impaired, absent, or spastic reactive) in 28 (70%). Delayed emptying on BE was numerically more frequent with abnormal FLIP (6% vs. 0%, p = 0.08). IGP post‐EGJ closure (median 21.8 vs. 15 mmHg, p = 0.03) and ∆ IGP post‐EGJ closure—IGP baseline (median 4 vs. 0 mmHg, p = 0.02) were greater and predictive of abnormal contractility on FLIP (OR 1.11, 95% CI 1.00–1.2, p = 0.03 and OR 1.6, 95% CI 1.07–2.39, p = 0.003, respectively).DiscussionAbnormal contractility on FLIP, reflecting disordered secondary peristalsis, frequently occurs despite normal HRM findings after MBS. Secondary peristalsis may be associated with reduced gastric compliance, reflected by elevated proximal intragastric pressure. FLIP contractility could serve as an early marker for post‐MBS esophageal dysfunction.

OBJECTIVE Despite the known negative physiological impact of repeated mild head trauma events, their multiplicative impact on long-term seizure risk remains unclear. The objective of this study was to evaluate how multiple mild traumatic brain injuries (mTBIs) impact long-term seizure risk by testing 3 distinct machine learning approaches. Baseline and injury-specific characteristics were incorporated to enhance prognostication of individual seizure risk. METHODS Children with at least 1 mTBI event without prior evidence of seizure or antiepileptic drug treatment, from 2003 to 2021, were identified from a nationally sourced administrative claims database. The primary outcome of interest was a seizure event after mTBI, defined by qualifying principal diagnosis codes. Time-varying multivariable Cox regression was used to assess the impact of repeated mTBI. RESULTS A total of 156,118 children (mean age 11.7 ± 4.7 years) were included, with a median follow-up duration of 22.6 months (IQR 9.2–45.4 months). Among patients who experienced seizure after mTBI, the median time to seizure was 306 days. Seizures among those with radiographic findings and/or loss of consciousness occurred earlier (median time to seizure 112.5 days [imaging findings only, IQR 5–526.25 days], 80 days [loss of consciousness only, IQR 7–652 days], 22 days [both, IQR 5–192 days]). Both mTBI without and with short-term loss of consciousness resulted in increasing seizure risk with repeated trauma (HR 1.196, 95% CI 1.082–1.322; HR 2.025, 95% CI 1.828–2.244; respectively). The random survival forest approach achieved fixed-time areas under the receiver operating characteristic curve of 0.780 and 0.777 at 30 and 90 days after mTBI, and children predicted at high risk by the final model experienced a significantly higher burden of early seizure after mTBI (46.7% within the first 30 days vs 17.7% and 19.9% of children at low and medium risk). A simplified model using the top 12 contributing features achieved 95% of the full model’s performance in the validation set. CONCLUSIONS A novel machine learning model was developed and validated for personalized prediction of long-term seizure risk following multiple mTBIs. Model performance remained robust with a limited feature set, suggesting the feasibility of real-time incorporation into clinical workflows for individualized prognostication following each repeat mTBI event. In children predicted to be at high risk, early intervention should be considered.

Summary Introduction Peroral plication of the esophagus (POPE) can reduce sump size and improve symptoms in end-stage achalasia. However, its long-term efficacy and safety are unknown. Methods Patients with end-stage achalasia who underwent POPE at our institution (2016–2024) were identified. Data were abstracted for patient demographics, procedural details, and clinical and radiographic outcomes. Results Twelve patients underwent POPE. The technical success rate was 100%, with mean procedural time of 57 minutes and without adverse events. Symptomatic improvement occurred in 75% of patients (mean follow-up of 15 months), while 86% had radiographic improvement in sump size. Repeat POPE in 6 (50%) patients a mean of 2.6 years after index POPE and a third POPE in four (33%) patients a mean of 3.1 years later was performed, with similar technical success rates and outcomes to the index POPE. Conclusions POPE is a safe and repeatable long-term therapeutic option in end-stage achalasia.