3ABNORMAL ESOPHAGEAL MOTILITY Data obtained from 95 healthy volunteers: age 22-74“Abnormal” defined1)Exceeding 2 SD from meanHypertensive LES > 45 mmHgHypotensive LES < 10 mmHgIncomplete LES relaxation (RP > 8 mmHg)Nutcracker esophagus > 180 mmHg
4ABNORMAL ESOPHAGEAL MOTILITY 2)Exceeding # found in any subject from 10 liquid swallowsDiffuse spasm > 20% simultaneous contractionsIneffective motility > 30% with amplitude <30 mmHgRichter J et al: Dig Dis Sci 33:583, 1987
5ESOPHAGEAL FUNCTION TESTING IN 2011: The New Toys Multichannel Intraluminal Impedance and pH: MII-pHMultichannel Intraluminal Impedance and manometry: MII-EMHigh Resolution Manometry: HRMHigh Resolution Impedance Manometry: HRIM
6GERD DIAGNOSISHistory: Not specific (i.e. functional heartburn)Trial of PPI Rx: standard of careEndoscopyErosive esophagitis: Not sensitive (modified by PPI)Biopsy: on again; off againDilated Intracellular Spaces: SpecificManometry: neither sensitive nor specificProlonged pH metry: Gold standard for yearsNeither sensitive nor specificCombined impedance-pH: “The most sensitive test for reflux” (Sifrim et al: GUT, 2004; 53: 1024)
7EVALUATING ESOPHAGEAL MOTILITY WITH THE NEW TOYS EM, MII-EM, HRM AND HRIM Devilsand dinosaurs!
15MANOMETRY VS BOLUS TRANSIT(MII) AFTER FUNDOPLICATION (80 PATIENTS; 33 MONTHS) p=nsp=0.01p=nsp<0.05Post-fundoplication MII may detect abnormalities in esophageal motility not detected by manometry.Yigit et al. Dis Esophagus 2006; 19:382-8
16IMPEDANCE TESTING INCREASES SENSITIVITY FOR DETECTING MOTILITY ABNORMALITIES (589 patients with normal manometry)(Koya et al: Dis Esophagus 2008; 21: 563)
17HIGH RESOLUTION IMPEDANCE MANOMETRY CATHETER 89105321112141516181920212223710 cm (HPZ)2425-1-2-3-4-5-6642627282935 cm pressure sensor spanHIGH RESOLUTION IMPEDANCE MANOMETRY CATHETER
21BOLUS TRANSIT DATA FROM MII PRESSURE DATA FROM EM
22HIGH RESOLUTION MANOMETRY Clinical perspective Motility diagnoses similar to conventional classification“Segmental nutcracker” and “spastic nutcracker” definedMay detect abnormalities of the length of the “transition zone”Nuances in analysis of pressure topographic plot“eSleeve” measurement of LES relaxation: multiple (3-4) adjacent sites:Integrated Relaxation Pressure (IRP)“Contractile front velocity” (CFV): isobaric pressure-time relationship of peristaltic movement“Distal contractile integral” (DCI): pressure/time/distance integrated measure of peristaltic amplitudeWhether this tool will be “valuable in the clinical management of esophageal motility disorders” remains to be established(Pandolfino et al: Am J Gastroenterol 2008, 103:27-37)
24DIAGNOSIS OF ACHALASIA This patient is a 35 year old male who has been having progressive dysphagia to solids and liquids.A barium swallow was consistent with achalasia.However, esophageal manometry was somewhat incongruent. His mean LES pressure was 24 mmHg and relaxation was achieved most of the time. Interestingly, the body of the esophagus demonstrated no progression of peristaltic waves.From a referring physician
25MANOMETRY FINDINGS IN ACHALASIA 73 consecutive patients38 female; age yearsAbsent peristalsis %(required)Incomplete LES relaxation %Elevated LES pressure %All 3 of above %Increased esophageal pressure %All 4 of above %(Agrawal et al: J Clin Gastro 2008; 42: 266)
33MANOMETRIC DIAGNOSIS OF HIATAL HERNIA FeaturesDouble high pressure zone (“double hump”)PIP at distal HPZSeen best with HH >5cm (Klaus)153 patients having both EM & endoscopyManometry: 11/153 (7%). (10 seen on endo)Endoscopy: 51/153 (33%)Manometry has low sensitivity (20%) but high specificity (99%) for hiatal hernia detected by endoscopy(Agrawal A et al: Dis Esoph 2005, 18:316)(Klaus A et al: Dig Dis 18: 172, 2000)
37EFT TESTING OF DES PATIENTS Demographics 71 patients with DESFemales 43 (60%), males 28 (40%)Age: mean 57 years, range yearsPresenting symptomDysphagia (32; 45%)Chest pain (16; 22%)GERD symptoms (23; 33%)Over a nine-month period we studied 350 patients and identified 70 patient with manometric patterns of IEM, 35 females and 35 males with a mean age of 54 years ranging from Each patient had 10 liquid and 10 viscous swallows providing a total of 700 liquid and 700 viscous swallows for analysis.Given the limited time I’m going to present primarily the results from the liquid swallows.
38DISTAL ESOPHAGEAL SPASM Definition: 2 or more liquid swallows with simultaneous onsetWhat is simultaneous?Truly simultaneousRetrogradeFast antegrade(>8 cm/sec)Over a nine-month period we studied 350 patients and identified 70 patient with manometric patterns of IEM, 35 females and 35 males with a mean age of 54 years ranging from Each patient had 10 liquid and 10 viscous swallows providing a total of 700 liquid and 700 viscous swallows for analysis.Given the limited time I’m going to present primarily the results from the liquid swallows.
43RESULTS OF COMBINED MII-EM IN DES MII provides additional information on the functionaldefect in DESPatients with a manometric diagnosis of DES are a heterogeneous groupCombined MII-EM testing may help direct appropriate therapy for patients in different groups:Chest pain, high pressure, normal transitDysphagia, low amplitude, abnormal transit(Tutuian R et al: Am J Gastro 2006; 101: 464)
45“INEFFECTIVE” PERISTALSIS Defect in esophageal peristalsisNon-transmittedHypotensive (< 30mmHg)*Based on study of 95 normal subjects:> 3 (30%) wet swallows showing ineffective peristalsis at either distal siteKahrilas et al: Gastroenterology 1988; 94:73-80Richter et al: Dig Dis Sci 1987; 33: 583
46INEFFECTIVE ESOPHAGEAL MOTILITY (IEM) IS A SPECIFIC MOTILITY ABNORMALITY # of NEMD PatientsLeite, L. et al: Dig Dis Sci 42:1853, 1997
48MII-EM IN PATIENTS WITH IEM (LIQUID) (N=70) 26/31 normal9/39 normal
49EVALUATION OF IEMCombined MII-EM assesses function of motility abnormalities not shown by EM aloneFactors determining complete/incomplete bolus transitAmplitude of esophageal contractions (DEA <25 mmHg)Number of swallows with low amplitudes (>5)(Tutuian R, Castell D: Clin Gastro Hepatol 2: 2004)
50ADVANTAGES OF COMBINED HRIM UES activity is easily seenAlso excellent swallow markerIdentify potential transition zone abnormalitiesIdentify achalasia typesBetter recognition of LES dynamicsParticularly relaxation residual pressureIntrabolus pressure easier to identifyBetter placement of reflux probe (HH seen)Disadvantage: will it violate rule #1?