Exaggerated smooth muscle contraction segments on esophageal high-resolution manometry: Prevalence and clinical relevance

M. D. Mello, S. Duraiswamy, L. H. Price, Y. Li, A. Patel, C. Prakash Gyawali

Research output: Contribution to journalArticlepeer-review

10 Scopus citations


Background: Two smooth muscle contraction segments (S2, S3) on esophageal high-resolution manometry (HRM) demonstrate varying contraction vigor in symptomatic patients. Significance of isolated exaggerated smooth muscle contraction remains unclear. Methods: High-resolution manometry studies were reviewed in 272 consecutive patients (56.4 ± 0.8 years, 62% F) and compared to 21 healthy controls (27.6 ± 0.6 years, 52% F), using HRM tools (distal contractile integral, DCI; distal latency, DL; integrated relaxation pressure, IRP), Chicago Classification (CC) and multiple rapid swallows (MRS). Segments were designated merged when the trough between S2 and S3 was ≥150 mmHg, and exaggerated S3 when peak S3 amplitude was ≥150 mmHg without merging with S2. Presenting symptoms and global symptom severity (on 100 mm visual analog scale) were recorded. Prevalence of merged and exaggerated segments was determined, and characteristics compared to symptomatic patients with normal HRM, and to healthy controls. Key Results: Merged segments were identified in 5.6%, and exaggerated S3 in another 12.5%, but only 17-50% had a CC diagnosis; one healthy control had merged segments. DCI with wet swallows was similar in cohorts with merged and exaggerated segments (p = 0.7), significantly higher than symptomatic patients with normal HRM and healthy controls (p ≤ 0.003 for each comparison). Incomplete inhibition and prominent DCI augmentation on MRS (p ≤ 0.01), and presenting symptoms (chest pain and dysphagia, p = 0.04) characterized exaggerated segments, but not demographics or symptom burden. Conclusions & Inferences: Merged esophageal smooth muscle segments and exaggerated S3 may represent hypermotility phenomena from abnormal inhibition and/or excitation, and are not uniformly identified by the CC algorithm. Isolated exaggeration of smooth muscle contraction segments are intermittently encountered on esophageal high-resolution manometry (HRM), but the prevalence and significance of these findings are not well characterized. We report low prevalence of both merged smooth muscle contraction segments and disproportionately exaggerated S3 (third segment) on HRM, and that these abnormalities can rarely be seen in healthy individuals. When encountered, these abnormalities are associated with abnormal esophageal inhibition and exaggerated contraction metrics on esophageal provocative testing, similar to hypermotility disorders identified by the Chicago Classification. Typical symptoms associated with these findings are chest pain and dysphagia. We conclude that isolated exaggerated smooth muscle contractions segments are part of the spectrum of esophageal hypermotility, but are not often identified by the Chicago Classification algorithm.

Original languageEnglish
Pages (from-to)229-236
Number of pages8
JournalNeurogastroenterology and Motility
Issue number2
StatePublished - Feb 1 2015


  • Distal contraction vigor
  • Exaggerated S3
  • High-resolution manometry
  • Merged contraction segments


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