1. ESOPHAGEAL FUNCTION TESTING IN 2011
Donald O. Castell M.D.
Professor of Medicine
Director, Esophageal Disorders Program
Medical University of South Carolina

3. ABNORMAL ESOPHAGEAL MOTILITY
Data obtained from 95 healthy volunteers: age 22-74
“Abnormal” defined
1)Exceeding 2 SD from mean
Hypertensive LES > 45 mmHg
Hypotensive LES < 10 mmHg
Incomplete LES relaxation (RP > 8 mmHg)
Nutcracker esophagus > 180 mmHg

4. ABNORMAL ESOPHAGEAL MOTILITY
2)Exceeding # found in any subject from 10 liquid swallows
Diffuse spasm > 20% simultaneous contractions
Ineffective motility > 30% with amplitude <30 mmHg
Richter J et al: Dig Dis Sci 33:583, 1987

5. ESOPHAGEAL FUNCTION TESTING IN 2011: The New Toys
Multichannel Intraluminal Impedance and pH: MII-pH
Multichannel Intraluminal Impedance and manometry: MII-EM
High Resolution Manometry: HRM
High Resolution Impedance Manometry: HRIM

6. GERD DIAGNOSIS
History: Not specific (i.e. functional heartburn)
Trial of PPI Rx: standard of care
Endoscopy
Erosive esophagitis: Not sensitive (modified by PPI)
Biopsy: on again; off again
Dilated Intracellular Spaces: Specific
Manometry: neither sensitive nor specific
Prolonged pH metry: Gold standard for years
Neither sensitive nor specific
Combined impedance-pH: “The most sensitive test for reflux” (Sifrim et al: GUT, 2004; 53: 1024)

7. EVALUATING ESOPHAGEAL MOTILITY WITH THE NEW TOYS EM, MII-EM, HRM AND HRIM
Devils
and dinosaurs!

9. THE PRIMARY PERISTALTIC WAVE TRANSPORTS FOOD THROUGH THE ESOPHAGUS
(Kahrilas: Gastroenterology 1988)

10. COMBINED MII-EM CATHETER
Esophagus Body
LES
Circumferential Sensors
20 cm
15 cm
10 cm
5 cm
LES HPZ

11. NORMAL IMPEDANCE-MANOMETRY (MII-EM) WITH COMPLETE BOLUS TRANSIT

12. INCOMPLETE BOLUS TRANSIT

13. COMBINED MII-EM IN 350 PATIENTS Percent patients with normal bolus transit (liquid)
(Tutuian & Castell: Am J Gastroenterol 2004; 99: 1011)

14. ESOPHAGEAL MOTILITY ABNORMALITIES
Abnormal Transit
Achalasia
Scleroderma
Ineffective esophageal motility
Distal esophageal spasm
Abnormal Pressure Only
Nutcracker esophagus
Hypertensive LES
Hypotensive LES
Incomplete LES relaxation

15. MANOMETRY VS BOLUS TRANSIT(MII) AFTER FUNDOPLICATION (80 PATIENTS; 33 MONTHS)
p=ns
p=0.01
p=ns
p<0.05
Post-fundoplication MII may detect abnormalities in esophageal motility not detected by manometry.
Yigit et al. Dis Esophagus 2006; 19:382-8

16. IMPEDANCE TESTING INCREASES SENSITIVITY FOR DETECTING MOTILITY ABNORMALITIES (589 patients with normal manometry)
(Koya et al: Dis Esophagus 2008; 21: 563)

17. HIGH RESOLUTION IMPEDANCE MANOMETRY CATHETER8 9 10 5 3 2 11 12 14 15 16 18 19 20 21 22 23 7 1
0 cm (HPZ) 24 25 -1 -2 -3 -4 -5 -6 6 4 26 27 28 29
35 cm pressure sensor span
HIGH RESOLUTION IMPEDANCE MANOMETRY CATHETER

18. HIGH RESOLUTION MANOMETRY
UES
UES relaxation
Distance from nares (mm)
Esophageal body
Pressure scale
LES
LES relaxation

19. Transition Zone

20. HIGH RESOLUTION IMPEDANCE MANOMETRY

21. BOLUS TRANSIT DATA FROM MII
PRESSURE DATA FROM EM

22. HIGH RESOLUTION MANOMETRY Clinical perspective
Motility diagnoses similar to conventional classification
“Segmental nutcracker” and “spastic nutcracker” defined
May 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 amplitude
Whether 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)

24. DIAGNOSIS 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

25. MANOMETRY FINDINGS IN ACHALASIA
73 consecutive patients
38 female; age years
Absent 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)

26. HRiM

27. SYSTEMIC SCLEROSIS

28. SCLERODERMA Esophageal involvement
Muscle replaced by connective tissue
Occurs in >75% of cases
Preferentially affects smooth muscle

29. SYSTEMIC SCLEROSIS Esophageal endoscopic ultrasound

33. MANOMETRIC DIAGNOSIS OF HIATAL HERNIA
Features
Double high pressure zone (“double hump”)
PIP at distal HPZ
Seen best with HH >5cm (Klaus)
153 patients having both EM & endoscopy
Manometry: 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)

37. EFT TESTING OF DES PATIENTS Demographics
71 patients with DES
Females 43 (60%), males 28 (40%)
Age: mean 57 years, range years
Presenting symptom
Dysphagia (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.

38. DISTAL ESOPHAGEAL SPASM
Definition: 2 or more liquid swallows with simultaneous onset
What is simultaneous?
Truly simultaneous
Retrograde
Fast 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.

39. SALINE SWALLOWS (N=710) Normal Simultaneous (N=303) Ineffective (N=51)
Retrograde
(N=49)
Simultaneous
(N=22)
Antegrade
(N=232)
Complete BT
Incomplete BT

40. SIMULTANEOUS SWALLOWS IN DES PATIENTS

41. DISTAL ESOPHAGEAL AMPLITUDE IN DES

42. COMPLETE BOLUS TRANSIT IN DES PATIENTS

43. RESULTS OF COMBINED MII-EM IN DES
MII provides additional information on the functional
defect in DES
Patients with a manometric diagnosis of DES are a heterogeneous group
Combined MII-EM testing may help direct appropriate therapy for patients in different groups:
Chest pain, high pressure, normal transit
Dysphagia, low amplitude, abnormal transit
(Tutuian R et al: Am J Gastro 2006; 101: 464)

45. “INEFFECTIVE” PERISTALSIS
Defect in esophageal peristalsis
Non-transmitted
Hypotensive (< 30mmHg)*
Based on study of 95 normal subjects:
> 3 (30%) wet swallows showing ineffective peristalsis at either distal site
Kahrilas et al: Gastroenterology 1988; 94:73-80
Richter et al: Dig Dis Sci 1987; 33: 583

46. INEFFECTIVE ESOPHAGEAL MOTILITY (IEM) IS A SPECIFIC MOTILITY ABNORMALITY
# of NEMD Patients
Leite, L. et al: Dig Dis Sci 42:1853, 1997

48. MII-EM IN PATIENTS WITH IEM (LIQUID) (N=70)
26/31 normal
9/39 normal

49. EVALUATION OF IEM
Combined MII-EM assesses function of motility abnormalities not shown by EM alone
Factors determining complete/incomplete bolus transit
Amplitude of esophageal contractions (DEA <25 mmHg)
Number of swallows with low amplitudes (>5)
(Tutuian R, Castell D: Clin Gastro Hepatol 2: 2004)

50. ADVANTAGES OF COMBINED HRIM
UES activity is easily seen
Also excellent swallow marker
Identify potential transition zone abnormalities
Identify achalasia types
Better recognition of LES dynamics
Particularly relaxation residual pressure
Intrabolus pressure easier to identify
Better placement of reflux probe (HH seen)
Disadvantage: will it violate rule #1?

51. ENTHUSIASM
TIME

52. TRUTH
The mind is like an umbrella:
It works best when it is open!

53. TRUTH “You should be less threatened by what you don’t know,
Than by what you believe you know that really ain’t so”
Mark Twain