Gastroesophageal Reflux Disease (GERD) is a common gastrointestinal disorder with considerable global prevalence and regional variability. Epidemiological data suggest that GERD affects approximately 18.1–27.8% of the population in the United States, 8.8–25.9% in Europe, and less than 10% in most Asian countries. GERD significantly compromises patients’ quality of life due to persistent pain, discomfort, and other symptoms such as heartburn and regurgitation.1 More importantly, GERD is recognized as a major risk factor for the development of Barrett’s esophagus and esophageal adenocarcinoma. The pathogenesis of GERD is multifactorial, and abnormal esophageal motility has been identified as a critical factor contributing to both the onset and progression of the disease.2 Delayed esophageal clearance of refluxate results in prolonged mucosal exposure to gastric and duodenal contents, thereby increasing the risk of esophagitis and its associated complications.3Studies have demonstrated that ineffective esophageal motility (IEM) is prevalent in 40–50% of patients with GERD. Additionally, variations in esophageal motility patterns have been observed across different GERD subtypes, with abnormalities in motility and low lower esophageal sphincter (LES) pressure being more commonly associated with endoscopic esophagitis. High-Resolution Manometry (HRM), an advanced diagnostic tool, allows for detailed evaluation of esophageal motor function4. By providing a comprehensive pressure profile from the upper to the lower esophageal sphincter, HRM has become the gold standard for diagnosing esophageal motility disorders.5 The introduction of the Chicago Classification (version 3.0) has further standardized the interpretation of HRM findings. A recent advancement in HRM is the development of a new metric known as the Esophagogastric Junction Contractile Integral (EGJ-CI), which aims to quantify the barrier function of the esophagogastric junction (EGJ). The EGJ-CI is calculated using a method similar to that used for determining the distal contractile integral (DCI). It involves measuring the pressure generated by the LES and crural diaphragm over three respiratory cycles, using gastric pressure as the threshold 6. The resulting value is divided by the duration of the respiratory cycles, thereby normalizing the metric to time and expressing it in units of mmHg•cm. 7 Several research groups have evaluated the utility of EGJ-CI in differentiating GERD subgroups, with consistent findings that a low EGJ-CI is associated with severe barrier dysfunction, endoscopic esophagitis, and abnormal reflux profiles. Despite its promise, the variability in EGJ-CI measurements across studies indicates methodological inconsistencies, particularly regarding the precise technique used for calculating the metric. In light of these discrepancies,8,9 the Lyon Consensus has acknowledged the potential of EGJ-CI but emphasized the need for further research before it can be widely adopted in clinical practice. Given this background, we conducted a study to assess the association between ineffective esophageal motility, low basal LES pressure, and EGJ-CI with endoscopic findings in GERD patients10. Using High-Resolution Manometry11, we aimed to provide further insights into the role of esophageal dysmotility and EGJ barrier function in GERD pathophysiology, thereby contributing to the optimization of diagnostic and therapeutic strategies for this prevalent and impactful disease.12 AIM To observe esophageal manometric abnormalities in patients with gastroesophageal reflux where esophageal manometry indicated.

The study was conducted in the Department of Gastroenterology at GMC Barmer. It was designed as an observational cross-sectional study aimed at evaluating esophageal motility and lower esophageal sphincter (LES) function in patients with gastroesophageal reflux disease (GERD). The study population included adult patients presenting with typical symptoms of GERD such as heartburn or acid regurgitation, as well as atypical symptoms like non-cardiac chest pain, epigastric burning, and excessive belching. To be eligible, patients were required to have experienced these symptoms at least twice a week for more than three months. Both outpatient (OPD) and inpatient (IPD) individuals referred to the gastroenterology department during the study period were considered for inclusion. Inclusion criteria were: adult patients aged 18 years and above with typical or atypical reflux symptoms occurring at least twice weekly for over three months, those being evaluated prior to anti-reflux surgery, and GERD patients unresponsive to medical therapy. Participation in the study was contingent upon obtaining informed consent from all patients. Exclusion criteria comprised patients diagnosed with achalasia, esophageal or fundic varices, a history of gastric or esophageal surgery, esophageal malignancy, or prior ingestion of corrosive substances. Additionally, individuals with acute cardiovascular or respiratory conditions, those who were pregnant, or who were unwilling to participate were excluded from the study.

Table 1:-Distribution of demographic characteristics of study subjects. Demographic characteristics Frequency Age(years) Mean ± SD 47.2 ± 17.2 Median(25th-75th percentile) 44.5(34-60.25) Range 20-80 Gender Female 33 Male 43 A total of 76 individuals were recruited for the study. The mean age of the patients was 47.2 ± 17.2 years .Out of 76 Individuals, there were 43 (56.58%) male and 33(43.42%) female patients. Table 2:-Distribution of symptoms of study subjects. Symptoms Frequency Percentage Heart burn 61 80.26% Non cardiac chest pain 34 44.74% Dry cough 1 1.32% Difficulty in swallowing 9 11.84% Epigastric burning 1 1.32% Belching 1 1.32% In our study, individuals presented with symptoms of Heart burn were 61(80.26%),Non Cardiac chest pain were 34(44.74%) ,difficulty in swallowing were 9(11.84%), and dry cough ,epigastric burning and belching were 1(1.32%). Table 3: Distribution of manometry outcome of study subjects. Manometry outcome Frequency Percentage Ineffective esophageal motility 24 31.58% Normal 52 68.42% Total 76 100.00% Out of 76 individuals, 24(31.58%) showed ineffective esophageal motility and 52(68.42%) showed normal esophageal motility on esophageal manometry. Table 4:-Distribution of hiatus hernia of study subjects. Hiatus hernia Frequency Percentage No 70 92.11% Yes 6 7.89% Total 76 100.00% Out of 76 individuals, Hiatus Hernia was seen in 6(7.89%) individual. Table 5: Distribution of basal LES pressure of study subjects. Basal LES pressure Frequency Percentage Normal 68 89.47% Reduced 8 10.53% Total 76 100.00% Out of 76 individuals, 8 (10.53%) patients showed reduced basal LES pressure and 68(89.47%) patients showed normal basal LES pressure on Esophageal manometry. Table 6: Distribution of Esophago gastro duodenoscopy of study subjects. Esophago gastro duodenoscopy Frequency Percentage Erosive reflux disease 46 60.53% Non erosive reflux disease 30 39.47% Total 76 100.00% In our study, on Esophago-gastro-duodenoscopy {EGD} of 76 individuals , 46 (60.53%) had Erosive esophasitis (Erosive reflux disease) and 30(39.47%) had non erosive reflux disease(normal appearing esophagus ). In our study, out of 46 individuals with erosive reflux disease, 15(32.61%) showed ineffective esophageal motility and 31(67.39%) showed normal esophageal motility and out of 30 individuals with non erosive reflux disease, 9(30%) showed ineffective esophageal motility and 21(70%) showed normal esophageal motility with p value 0.881 which was not statically significant. Out of 46 individuals with erosive reflux disease ,40 (86.96%) showed normal Basal LES pressure and 6(13,04%) showed reduced Basal LES pressure. 30 individuals with Non erosive reflux disease, 28(93.33%) showed normal Basal LES pressure and only 2(6.67%) showed reduced Basal LES pressure with p value of 0.468 which was not statically significant. Table 7: Association of esophagogastric Junction Contractility Integral with esophago gastro duodenoscopy. Esophagogastric Junction Contractility Integral Erosive reflux disease(n=46) Non erosive reflux disease(n=30) Total P value Mean ± SD 47.93 ± 27.6 49.9 ± 26.86 48.71 ± 27.15 0.76* Median(25th- 75th percentile) 47.2 (28.3-60.675) 46.8 (33.375-70.775) 47.1 (28.5-66.8) Range 6.3-112.1 5.1-114.6 5.1-114.6 In our study, the association of esophagogastric junction contractile integral with endoscopic results had mean value for erosive reflux disease is 47.93 and for non erosive reflux disease mean value was 49.90 with p value 0.76. Table 8: Receiver operating characteristics of Esophagogastric Junction Contractility Integral for predicting Erosive reflux disease. Erosive reflux disease Esophagogastric Junction Contractility Integral Erosive reflux disease Area under the ROC curve (AUC) 0.521 Area under the ROC curve (AUC) Standard Error 0.0687 Standard Error 95% Confidence interval 0.403 to 0.637 95% Confidence interval P value 0.764 P value Cut off ≤20.9 Cut off Sensitivity(95% CI) 23.91% (12.6 - 38.8%) Sensitivity(95% CI) Specificity(95% CI) 86.67% (69.3 - 96.2%) Specificity(95% CI) PPV(95% CI) 73.3% (44.9 - 92.2%) PPV(95% CI) NPV(95% CI) 42.6% (30.0 - 55.9%) NPV(95% CI) Diagnostic accuracy 48.68% Diagnostic accuracy In our study ,receiver operating characteristics of esophageal junction contractile integral for predicting erosive reflux disease showed cut off value<20.9 with p value 0.764 ,sensitivity is about 23.91% and specificity is about 86.67% .Positive predictive value is 73.3% with NPV of 42.6% and diagnostic accuracy was about 48.68 %

A total of 76 individuals were recruited for the study. Out of 76 Individuals, there were 56.58% male and 43.42% female patients and the age of patients ranged from 20 to 80 years. In our study, most of the individuals presented with symptoms of Heartburn were 61(80.26%),Non Cardiac chest pain were 34(44.74%) ,difficulty in swallowing were 9(11.84%), epigastric burning, dry cough , and belching in 1(1.32%) in each . A similar Study by Broderick at al reported heart burn was the most frequent chief complaint found in 61% of patients13. Among 76 individuals, 31.58% showed ineffective esophageal motility, 10.53% patients showed reduced basal LES pressure and 7.89% showed hiatus hernia. This, when compared with a previous study by deepalakami K et al, showed similar results as 26.7% were found to be ineffective esophageal motility, 11.7% had low LES pressure in this study and 2.64% patients had hiatus hernia14 . Ineffective esophageal motility was seen more frequently in patients of erosive reflux disease (32.6%) in comparison to patients with non-erosive reflux disease (30%); although the difference was statistically not significant (p=0.881). Study by Daum et al found similar results as peristaltic dysfunction in 56% of Non Erosive reflux disease (NERD) and 76% of Erosive Reflux Disease (ERD), they also observed that esophageal motility disorders was reported higher in GERD patients using HRM than with conventional manometry15 but in our study due to limitation of resources we used only HRM. Study by Deepalaxshmi K et al found ineffective esophageal motility more among patients with erosive reflux disease when compared to non erosive reflux disease14. This is in contrast with study by Lemme et al reported that there was no difference observed in the prevalence of Ineffective Esophageal Motility among non-erosive (38%) and erosive (38%) GERD patients16. Simren et al, also suggested that Ineffective Esophageal Motility had little influence on esophageal clearance during upright acid reflux and only severe esophageal motility disturbances, were associated with prolonged esophageal clearance in those with supine reflux17. On Esophago-gastro-duodenoscopy (EGD), out of 46 individuals with erosive reflux disease , 13.04% showed low Basal LES pressure. While in individuals with Non erosive reflux disease, only 6.67% showed reduced Basal LES pressure, which was statistically not significant (p=0.468). Similar results were found in a study by deepalakshmi, low LES pressure was found to be reported higher among patients with erosive reflux disease than in patients with Non-erosive reflux disease14. Another study by Frazzoni et al in a comparative study conducted among GERD patients had observed lower mean LES pressure in patients with erosive and non-erosive reflux disease compared to control group18. The association of esophagogastric junction contractile integral with endoscopic results had low mean value (47.93) for erosive reflux disease and high mean value (49.90) for non erosive reflux disease. In our study ,receiver operating characteristics of esophageal junction contractile integral for predicting erosive reflux disease showed cut off value<20.9 with p value of 0.764; sensitivity was about 23.91% and specificity was about 86.67% .Positive predictive value is 73.3% with NPV of 42.6% and diagnostic accuracy was about 48.68 %.A study by Ham et al showed EGJ-CI were lower in patients with GERD (22.6 [13.8–29.2] mmHg cm) than non-GERD (50.3 [31–69.9] mmHg cm, P < 0.01) and controls (67 [26.7–78.7] mmHg cm). With an EGJ-CI cut-off value of 30 mmHg cm, the area under the curve was 0.814 (0.762–0.896), with 77.8% sensitivity and 81.7% specificity for the prediction of GERD. Our study have low sensitivity and diagnostic accuracy but had high specificity and PPV , most likely due to we only used it for predicting erosive reflux disease and its low and variable cut off values, small study population and not having a control group (as done by Ham et al)19.

To conclude, Ineffective esophageal motility, low LES pressure, Low EGJ-CI and hiatus hernia were associated with GERD, but do not predict the disease with sufficient accuracy. Ineffective esophageal motility and low LES pressure was found higher in Erosive Reflux Disease in comparison to Non-Erosive Reflux Disease in our study . No significant association was observed for Ineffective Esophageal Motility or low LES pressure to predict endoscopic esophagitis. Esophagogastric junction contractile integral (EGJ-CI) showed low sensitivity and low diagnostic accuracy with high specificity and high PPV for predicting endoscopic esophagitis.

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