The Aging Esophagus: Contraction Reserve on High‐Resolution Manometry Declines With Age

BACKGROUND: Esophageal symptoms are common among elderly patients, although evidence on age-related esophageal dysfunction remains inconsistent. Esophageal contraction reserve measured by response to multiple rapid swallows (MRS) on high-resolution manometry (HRM) provides additional insights beyond conventional HRM metrics. We aimed to evaluate the impact of age on esophageal contraction reserve among symptomatic adults. METHODS: Adults with esophageal symptoms undergoing HRM and pH-impedance monitoring off acid suppression were included. Patients with prior foregut surgery or major peristaltic disorder were excluded. MRS response was assessed by the ratio of post-MRS distal contractile integral (DCI) to mean DCI from single water swallows, with a ratio > 1 defining a positive response (MRS+). RESULTS: Among 619 patients (mean 56.5 years, 59.1% female), 372 patients (60.1%) exhibited intact contraction reserve. MRS+ patients were younger (54.3 ± 15.7 vs. 59.8 ± 12.5 years, p < 0.0001) and MRS+ prevalence declined with advancing age groups (< 35 years: 78.8%; 35-50 years: 65.4%; 50-65 years: 59.6%; > 65 years: 51.7%, p-trend = 0.0008). On multivariable logistic regression, age negatively predicted MRS+ (OR: 0.97, CI: 0.96-0.99, p = 0.0004), after adjusting for potential confounders. In separate models constructed with categorized age groups, age > 65 years independently correlated with less MRS+ compared to all younger groups: Age < 35 (OR: 0.23, CI: 0.10-0.53, p = 0.0005), age 35-50 (OR: 0.58, 95% CI: 0.31-0.98, p = 0.045), and age 50-65 (OR: 0.55, 95% CI: 0.33-0.90, p = 0.017). CONCLUSION: Esophageal contraction reserve measured by MRS during HRM declines with advancing age. Age-related loss of contractile adaptability may contribute to esophageal dysfunction and unexplained symptoms in older adults. Provocative testing with MRS on HRM provides value in evaluating symptomatic elderly patients.