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

ESOPHAGEAL FUNCTION TESTING IN 2011

Donald O. Castell M.D.

Professor of Medicine

Director, Esophageal Disorders Program

Medical University of South Carolina

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

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

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

GERD DIAGNOSIS - 2011

• 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)

EVALUATING ESOPHAGEAL MOTILITY WITH THE NEW TOYS

EM, MII-EM, HRM AND HRIM

Devils and dinosaurs!

THE PRIMARY PERISTALTIC WAVE TRANSPORTS FOOD THROUGH THE ESOPHAGUS

(Kahrilas: Gastroenterology 1988)

COMBINED MII-EM CATHETER

Esophagus Body

LES

Circumferential Sensors

20 cm

15 cm

10 cm

5 cm

LES HPZ

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

INCOMPLETE BOLUS TRANSIT

COMBINED MII-EM IN 350 PATIENTS Percent patients with normal bolus transit (liquid)

0% 0%

51%55%

95% 97% 100%96%

100%

0%

20%

40%

60%

80%

100%

achalasia scleroderma IEM DES normal nutcracker poor relaxingLES

hypertensiveLES

hypotensiveLES

24 4 71 33 125 30 33 25 5

(Tutuian & Castell: Am J Gastroenterol 2004; 99: 1011)

ESOPHAGEAL MOTILITY ABNORMALITIES

Abnormal Transit Achalasia

SclerodermaIneffective esophageal motility

Distal esophageal spasm

Abnormal Pressure Only Nutcracker esophagus

Hypertensive LES Hypotensive LES

Incomplete LES relaxation

MANOMETRY VS BOLUS TRANSIT(MII) AFTER FUNDOPLICATION (80 PATIENTS; 33 MONTHS)

19

38

16

66

0

20

40

60

80

100

abn. Mano abn. MII

Perc

enta

ge o

f patients

(%

)

Normal anatomy Abnormal anatomy

17

61

14

32

0

20

40

60

80

100

Ineff. Peristalsis Incompl. Clearance

Perc

enta

ge o

f patients

(%

)

Dysphagia No dysphagia

p=ns p=0.01 p=ns p<0.05

Yigit et al. Dis Esophagus 2006; 19:382-8

IMPEDANCE TESTING INCREASES SENSITIVITY FOR DETECTING MOTILITY ABNORMALITIES

(589 patients with normal manometry)

(Koya et al: Dis Esophagus 2008; 21: 563)

0%

5%

10%

15%

20%

25%

30%

35%

40%

Dysphagia (p < 0.004) Heartburn (p < 0.04)

NL EM/NL MII (146)

NL EM/ABN MII (158)

8

910

5

3

2

11

12

141516

18

192021

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

HIGH RESOLUTION MANOMETRY

UES

LESLES relaxation

Dis

tanc

e fr

om n

ares

(m

m)

Eso

phag

eal b

ody

UES relaxation

Pre

ssur

e sc

ale

Transition Zone

Impe

danc

eM

anom

etry

HIGH RESOLUTION IMPEDANCE MANOMETRY

BOLUS TRANSIT DATA FROM MII

PRESSURE DATA FROM EM

HIGH RESOLUTION MANOMETRYClinical 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)

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

MANOMETRY FINDINGS IN ACHALASIA

• 73 consecutive patients38 female; age 14-95 years

• Absent peristalsis 100%(required)

• Incomplete LES relaxation 63%

• Elevated LES pressure 32%All 3 of above 23%

• Increased esophageal pressure 62% All 4 of above 4%

(Agrawal et al: J Clin Gastro 2008; 42: 266)

HRiM

SYSTEMIC SCLEROSIS

SCLERODERMAEsophageal involvement

• Muscle replaced by connective tissue

• Occurs in >75% of cases

• Preferentially affects smooth muscle

SYSTEMIC SCLEROSIS Esophageal endoscopic ultrasound

MANOMETRIC DIAGNOSIS OF HIATAL HERNIA

• FeaturesDouble high pressure zone (“double hump”)

PIP at distal HPZ

Seen 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)

EFT TESTING OF DES PATIENTSDemographics

• 71 patients with DES

Females 43 (60%), males 28 (40%)

Age: mean 57 years, range 16-85 years

• Presenting symptom

Dysphagia (32; 45%)

Chest pain (16; 22%)

GERD symptoms (23; 33%)

DISTAL ESOPHAGEAL SPASM

• Definition: 2 or more liquid swallows with simultaneous onset

• What is simultaneous?

– Truly simultaneous

– Retrograde

– Fast antegrade(>8 cm/sec)

SALINE SWALLOWS (N=710)Normal (N=356)

Simultaneous (N=303)

Ineffective (N=51)

Retrograde (N=49)

Simultaneous (N=22)

Antegrade (N=232)

Complete BT

Incomplete BT

SIMULTANEOUS SWALLOWS IN DES PATIENTS

0

1

2

3

4

5

6

7

8

9

10

chest pain dysphagia GERD

(N=16) (N=32) (N=23)

Nu

mb

er

of

sim

ult

an

eo

us s

wall

ow

s

Liquid

Viscous

DISTAL ESOPHAGEAL AMPLITUDE IN DES

Distal esophageal amplitude (DEA)

0.0

50.0

100.0

150.0

200.0

250.0

chest pain dysphagia GERD

(N=16) (N=32) (N=23)

mm

Hg

Liquid Viscous

COMPLETE BOLUS TRANSIT IN DES PATIENTS

Swallows with complete bolus transit

0

1

2

3

4

5

6

7

8

9

10

chest pain dysphagia GERD

(N=16) (N=32) (N=23)

Nu

mb

er

of

sw

all

ow

s

Liquid Viscous

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)

“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

0

2

4

6

8

10

12

0 1 2 3 4 5 6 7 8 9 10

# of Ineffective Contractions

# of NEMD

Patients

Leite, L. et al: Dig Dis Sci 42:1853, 1997

INEFFECTIVE ESOPHAGEAL MOTILITY (IEM) IS A SPECIFIC MOTILITY ABNORMALITY

1214

3 2 1 1 2

2

3

6

4

2

7

4

7

0

2

4

6

8

10

12

14

16

18

0 1 2 3 4 5 6 7 8 9 10

Number of ineffective swallows

Nu

mb

er

of

pati

en

ts

incomplete

complete

p < 0.001

26/31 normal 9/39 normal

MII-EM IN PATIENTS WITH IEM (LIQUID)(N=70)

• 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)

EVALUATION OF IEM

(Tutuian R, Castell D: Clin Gastro Hepatol 2: 2004)

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?

EN

TH

US

IAS

M

TIME

TRUTH

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

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