DYSPHAGIA - THE ROLE OF OESOPHAGEAL MOTILITY DISORDERS IAN WALLACE FCP(SA), FRACP. SHAKESPEARE SPECIALIST GROUP MILFORD, AUCKLAND
Dec 18, 2015
DYSPHAGIA - THE ROLE OF OESOPHAGEAL MOTILITY DISORDERS
IAN WALLACE FCP(SA), FRACP.SHAKESPEARE SPECIALIST GROUP
MILFORD, AUCKLAND
CAUSES OF DYSPHAGIA
HISTORY Oropharyngeal vs oesophageal body Duration and frequency (progressive?) Associated regurgitiation Associated reflux symptoms Solids to liquids vs solids and liquids
EXAMINATION Lymphadenopathy Neurological
CAUSES OF DYSPHAGIA
Structural abnormalities Oesophageal neoplasm Peptic stricture Shatzki ring Incarcerated hiatal hernia Oesophageal web Oesophageal diverticulae
CAUSES OF DYSPHAGIA
Motility disorders Non specific motility disorder
(ineffective oesophageal motility) Achalasia Eosinophilic oesophagitis Nutcracker oesophagus Diffuse oesophageal spasm Hypertensive LOS
CAUSES OF DYSPHAGIAMOTILITY DISORDERS Dig Dis Sci 1987;32:583
Dysphagia in 132 patients
NSMD
nutcracker
DOS
HLOS
Achalasia
CAUSES OF DYSPHAGIAMOTILITY DISORDERS
Special investigations Baseline bloods CXR Endoscopy and mucosal biopsy Barium swallow (marshmallow) Oesophageal manometry
32 Pressure Channels
High ResolutionImpedance-Manometry
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5
32
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1
0
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Impedance Technology Fundamentals
Reflux Bolus Conducts Electricity&
Current Flows Between Impedance Rings
Current Generat
or
A single impedance channel will detect bolus movement through the oesophagus
Multiple impedance channels are required to detect the direction of bolus movement
Impedance Technology Fundamentals
123456
Pressure
Impedance
Contour Plot View of Swallow with Normal Manometry & Complete Bolus Transit
Esophageal Body
Pharynx
UES
Esophageal Body
LES
Gastric
123456
Pressure
Manometry Waveforms
Bolus Transit Waveforms
Impedance
Contour Plot View of Swallow with Normal Manometry & Complete Bolus Transit
Impedance
Time
Impedance Contacts
Impedance Contacts
Impedance Technology Fundamentals
Bolus Entry Bolus Exit
Bolus Present
OESOPHAGEAL MOTILITY DISORDERSINEFFECTIVE OESOPHAGEAL MOTILITY
Common in patients with chronic reflux Predictive of refractory nocturnal GORD Characterized by a hypo contractile
oesophagus. (amplitude <30mmHg in >30% of contractions)
Failure of distal propagation of peristaltic wave
Oesophageal Motility Disorders Achalasia-Aetiology
Idiopathic- 98 % Primary Secondary
Familial Associated with other congenital
defects Associated with degenerative
neurological disease
Oesophageal Motility Disorders Achalasia - Symptoms
Dysphagia – usually slowly progressive
Regurgitation Chest pain and dysphagia Reflux symptoms
Oesophageal Motility Disorders Achalasia-Manometric features
Normal to raised LOS resting pressures
LOS fails to relax to gastric baseline Raised residual pressures Raised oesophageal baseline
pressures Absent or chaotic low amplitude
simultaneous peristalsis
Oesophageal Motility disorders Achalasia-Treatment
Pneumatic dilatatation Risks Patient selection
Botox injection Patient selection
Surgery Gastro-oesophageal reflux a
significant complication
Eosinophilic Esophagitis Definition:
Presence of eosinophils in the squamous epithelium or deeper
Number of Eosinophils/hpf ranged from 30 – 320 (mean 101)
Various studies have used 15-30/hpf Oesophagus - an immunologically active
organ Eosinophilic infiltration also seen in :
GORD Eosinophilic gastroenteritis Collagen vascular diseases Infections
Allergy Profile
Allergy history 90% Atopic illness 46% Food allergy 25% Family history of asthma
43% Blood eosinophils 36% IgE 56% Positive RAST 42%
Endoscopic features associated with EENonerosive changes extending along the whole esophagus
• Whitish pinpoint exudate or papules
• Granularity • Loss of vascular pattern • Linear furrow and fold pattern • Rings • Corrugation
Focal stricture (often proximal)
Long-segment stricture (small caliber esophagus)
Linear sheering of mucosa after dilation
Eosinophilic OesophagitisTreatment Options
Acid suppression (PPI therapy) where there are reflux symptoms PLUS:
Swallowed inhalers – e.g. fluticasone Antihistamine therapy (Loratidine) Corticosteroids
Elimination diets where specific allergies are defined
Role of Ranitidine Clin Gastro. And Hepatol.2004;2:523 - 530
Eosinophilic Oesophagitis - Conclusion
EE, a condition seen in children now increasing identified in adults
Should be considered in the relevant patient population & those not responding to standard reflux treatment
Awareness and recognition of gross changes by endoscopists
Importance of tissue sampling for subtle abnormalities
Establishing correct diagnosis may prevent unnecessary interventions, e.g. fundoplication
OESOPHAGEAL MOTILITY DISORDERSNUTCRACKER OESOPHAGUS
Most common cause of NCCP in those patients with an oesophageal motility disorder.
Average distal pressures > 180 mm Hg.
Peristalsis is normal so Ba studies usually normal.
90% present with chest pain.
DYSPHAGIACONCLUSIONS
The symptom of dysphagia does not always indicate a physical obstruction
Oesophageal motility disorders account for the majority of cases of dysphagia
A normal endoscopy or Ba study does not exclude a motility disorder - role of oesophageal manometry
Importance of mucosal biopsies of macroscopically normal mucosa