1. GI MOTILITY When Slow Doesn’t Always Win the Race
Presenter: Shirley Maltman, RN, CGN(c)

2. Disclosure
I will be mentioning the Covidien ManoScan Manometry system and the Crospon EndoFlip System in my presentation as products used by the Calgary GI Motility Clinic. There has been no compensation from either company.

3. Objectives
Discuss the correlation between symptoms and Manometry studies
Discuss conditions associated with Motility Disorders
Research studies that are in progress in Calgary

4. First a Quick Review

5. What is Esophageal Manometry?
Esophageal manometry is a study used to assess pressures and motor function of the esophagus. This aids in the evaluation of how well the muscles in the esophagus work to transport liquids or food from the mouth into the stomach.
Source: Medtronic Eso Training Resources

6. Why Order the Test? Atypical chest pain Reflux (GERD or NERD)
Dysphagia
Chronic cough
Pre-op assessment (Hiatal hernia repair, Fundoplication, Lung transplant)

7. Who Orders pH/Motility Studies?
Gastroenterology
General/Thoracic Surgery
Respirology
Lung Transplant Team
Rheumatology

8. Esophageal manometry
EM is done with a high resolution probe inserted nasally, down the esophagus to straddle the LES. It measures the how the muscles in the esophagus contract and with the Impedance function, measures how well the bolus is emptied from the esophagus. The procedure takes approx 10 min.
Source: Calgary Gut Motility Clinic

9. Basic Anatomy
Source: Google

10. Swallow and Bolus Movement

11. Normal
Source: Calgary GI Gut Motility Clinic

12. And Now for the Abnormal!!

13. Achalasia
Type III Type II Type I
Source: Google

14. Symptoms of Achalasia
Dysphagia for both solids and liquids which starts as an occasional occurrence but can progress to every mouthful
Regurgitation of food and fluid, especially when supine, and is often mixed with saliva and mucous
Chest pain or discomfort
Unintentional weight loss

15. Complications of Achalasia
If untreated in the early stages, the food that collects in the esophagus can spill into the lungs causing bronchitis, pneumonia, or chronic lung disease.
The retained food can also cause esophageal chronic irritation leading to fungal infections.
Other complications are weight loss, malnutrition, and an increased risk of esophageal cancer

16. Achalasia (Type III)
Vigorous achalsia with chest pain and dysphagia. Pan-esophagel pressur
Source: Calgary Gut Motilty Clinic

17. Achalasia (Type II)
Panesophageal pressurization is seen in Type II. Patient quite often feels a pressure-like chest discomfort with frequent “burping” to relieve the pressure
Source: Covidien

18. Achalasia (Type I)
This is considered to be a chronic state where the esophagus is now a “sigmoid esophagus”.
Source: Calgary Gut Motility Clinic

19. Treatment of Achalasia
Medical
Medication: Nitrates (Isorbide dinitrate), Calcium Channel Blockers (Nifedipine)
Botox Injection into the LES which is temporary and may be repeated.
Pneumatic Dilation
Surgical
Heller Myotomy (which may be done with or without a Loose fundoplication)
POEM (Peroral Endoscopic Myotomy)
Esophagectomy

20. Jackhammer Esophagus Formerly known as “Nutcracker Esophagus”
With the Chicago Classification system that we are using, it is now required that there be 2 or more of these very robust contractions to qualify as Jack Hammer Esophagus. Associated with chest pain and dysphagia.
Source: Calgary Gut Motility Clinic

21. Jackhammer Esophagus
Source: Google

22. Jackhammer Esophagus What is it?
Hypercontractile Esophagus in which the esophageal contractions are of a very high amplitude involving a majority of the esophagus with a prolonged duration.

23. Jackhammer Esophagus Symptoms A squeezing pain in the chest
Difficulty swallowing, especially extremely hot or cold fluids
A feeling that an object is caught in the throat
Treatment
Sildenafil (smooth muscle relaxant) lowers LES pressure and spastic contractions of the distal esophagus
Botox
Balloon Dilation
PPI (often ineffective)
Tricyclic antidepressants

24. Distal Esophageal Spasm
. This is defined as 20% or more premature contractions with normal contraction pressure (DCI >450 mmHg-c-s) and normal LES relaxation. Some normal peristalsis may be present. This finding may cause dysphagia, chest pain, or other symptoms.
Source: Calgary Gut Motility Clinic

25. Distal Esophageal Spasm
What is it??
A condition characterized by premature, uncoordinated contractions of the esophagus, which may cause difficulty swallowing (dysphagia) or regurgitation. In some cases, it may cause chest pain
Linked with Nitric Oxide deficiency resulting in a disordered neural inhibition. May progress to Achalasia
GERD frequently co-exists

26. DES (Distal Esophageal Spasm)
Treatment:
Calcium channel blockers, nitrates (both short and long-acting), anticholinergics, visceral analgesics (tricyclic agent or SSRO’s), and esophageal dilation.
Botox injection into the distal esophagus
Heller Myotomy or POEM for the rare refractory patient.

27. EGJ Outflow Obstruction
Defined as poorly relaxing LES (median IRP>15 mmHg), but with some preserved peristaltic function. Potential etiologies include early achalasia, mechanical obstruction, esophageal wall stiffness (due to inflammatory or infiltrative disease), or manifestation of hiatal hernia.
Source: Calgary Gut Motility Clinic

28. Hypotensive LES
Source: Covidien

29. IEM
Source: Calgary Gut Motility Clinic

30. Respiratory & Lung Transplant
Respirology will order Motility/pH to ensure chronic cough is not caused by reflux (acid or non-acid)
Done prior to lung transplants to ensure there is no underlying pre-condition

31. Hiatal Hernia 1/3 -1/2 of our studies done are for pre-op assessment
There needs to be assurance of adequate esophageal motility prior to a Nissen Fundoplication and Hiatal Hernia repair

32. Hiatal Hernia Types
Source: Google

33. Hiatal Hernia EGD View
Source: Google

34. Hiatal Hernia
Source: Calgary Gut Motility Clinic

35. Lap Band
Source: Calgary Gut Motility Clinic

36. Post-Vertical Sleeve Gastrectomy
Source: Calgary Gut Motility Clinic

37. Connective Tissue Disease
Scleroderma is thought to show up in the Gut first before the skin. Normal UES, absent peristalsis, and weak LES.
Source: Calgary Gut Motility Clinic

38. Scleroderma Study
In conjunction with Rheumatology and Stem Cell Transplant Clinic (at Tom Baker Cancer Center)
Pre-transplant manometry assessment, & months post-transplant.
5 patients have had pre-transplant assessment
3 patients have had 6 month post-transplant assessments…..

39. Scleroderma Study(patient 1)
Pre Stem Cell Transplant
Post-Stem cell Transplant (6 mos)
Source: Calgary Gut Motility Clinic

40. Scleroderma Study (patient 2)
Pre-stem cell transplant
Post-stem cell transplant (6 mos)
Source: Calgary Gut Motility Clinic

41. EndoFLIP(Functional Luminal Imaging Technology)
EndoFLIP is a technology that simultaneously measures the area across the inside of a gastrointestinal organ (for example, the esophagus) and the pressure inside that organ. The ratio of the two measurements is called distensibility (stiffness).
We can measure just the LES (in cases of Achalasia or EGJ Outflow Obstruction), or both LES and esophageal body (in EoE)

42. EndoFLIP Equipment
Source: Google

43. EndoFLIP Study The patient is NPO for 4 hours prior to the procedure
The procedure may be done during endoscopy or in the Motility Clinic unsedated (most of our patients are done this way)
Local anesthetic is sprayed into the oropharynx
The balloon catheter is inserted orally into the stomach and is inflated to 30 ml. The balloon is then withdrawn into the LES.

44. EndoFLIP Study Measurements are taken at the LES.
The balloon is then deflated and withdrawn into the body of the esophagus.
Inflation of the balloon is in increments and the patient is carefully monitored for discomfort.
The procedure takes approximately 5-10 minutes and is generally well-tolerated.

45. EndoFLIP LES
Source: Google

46. Eosinophilic Esophagitis (EoE)
Is an allergic reaction in which the lining of the esophagus reacts to allergens such as food or pollen
Eosinophils are normally in the GI tract, but in EoE, they multiply and produce a protein causing inflammation, leading to scarring, narrowing and excessive fibrotic tissue in the esophagus. This in turn causes symptoms of dysphagia or even bolus impaction.

47. Eosinophilic Esophagitis (EoE)
Confirmed with biopsy during EGD
Treated with PPI (for PPI-responsive EoE), elimination diet, steroids (Fluticasone or Budesonide orally), or dilation

48. EoE Esophageal manometry EndoFLIP
IEM is common in EoE. The diameter of the body of the esophagus is <17 mm therefore there is a greater risk of food bolus impaction.
Source: Calgary Gut Motility Clinic

49. EoE study EGD with biopsies (for diagnosis)
A dysphagia questionnaire, and EndoFLIP are done after diagnosis and before treatment is started.
EGD and EndoFLIP are repeated 3-6 months and months after treatment is started.

51. Thank you for your attention!
Source: Armadale Castle, Skye Maltman trip