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The following is a summary of “Diagnosis of Retrograde Cricopharyngeus Dysfunction Using High-Resolution Impedance Manometry and Comparison with Control Subjects,” published in the January 2025 issue of Clinical Gastroenterology and Hepatology by Raymenants et al. 

Retrograde cricopharyngeal dysfunction (R-CPD), commonly characterized by an inability to belch, has been attributed to ineffective relaxation of the upper esophageal sphincter (UES) during gastroesophageal gas reflux. While botulinum toxin (BT) injection into the UES has demonstrated efficacy in clinical case series, the condition remains frequently underdiagnosed. High-resolution impedance manometry (HRiM) with belch provocation has recently been proposed as a diagnostic modality for R-CPD, yet further validation is needed. This study aimed to confirm the diagnostic utility of HRiM with belch provocation in patients with R-CPD, assess the impact of BT treatment, and compare findings with control patients and healthy volunteers. 

A retrospective analysis was conducted on HRiM studies performed between May 2021 and April 2024, evaluating gas reflux episodes for UES relaxation, air clearance, air entrapment, and oscillatory air movements within the esophagus. A total of 100 participants were included: 55 patients presenting with symptoms suggestive of R-CPD, 30 control patients, and 15 healthy volunteers. Of the symptomatic cohort, 29 patients underwent repeat HRiM assessment following BT injection into the UES. Baseline manometric findings revealed significantly reduced esophageal contractility in R-CPD patients compared to control groups, with median distal contractile integral (DCI) values of 146, 577, and 316 mmHg·cm·s, respectively (adjusted P= 0.0109). 

During belching, patients with R-CPD exhibited significantly elevated UES pressures compared to controls, resulting in incomplete air clearance and persistent intraesophageal air oscillations (P< 0.0001). Following BT treatment, median UES pressure during belching decreased from 56 mmHg to 3 mmHg, accompanied by a significant improvement in air clearance (P< 0.0001). Furthermore, a maximum UES pressure threshold of >31 mmHg during belching effectively distinguished patients with R-CPD from controls, reinforcing the diagnostic potential of HRiM with belch provocation. 

These findings support the rapid drinking challenge with sparkling water as an effective belch provocation test, demonstrating its ability to identify elevated UES pressures and abnormal intraesophageal air dynamics in patients with R-CPD. In summary, HRiM with belch provocation provides objective physiological evidence of impaired UES relaxation in R-CPD and serves as a valuable tool for diagnosis and treatment monitoring.

Source: cghjournal.org/article/S1542-3565(25)00070-9/abstract