Participating in the Webinar

1

Participating in the Webinar

All attendees will be muted and will remain in Listen Only Mode.

Type your questions here so that the moderator can see them. Not all questions will be answered but we will get to as many as possible.

How to Receive CME and MOC Points

LIVE VIRTUAL GRAND ROUNDS WEBINAR

ACG will send a link to a CME & MOC evaluation to all attendees on the live webinar.

ABIM Board Certified physicians need to complete their MOC activities by December 31, 2021 in order for the MOC points to count toward any MOC requirements that are due by the end of the year. No MOC credit may be awarded after March 1, 2022 for this activity.

1

2

American College of Gastroenterology

2

MOC QUESTION

If you plan to claim MOC Points for this activity, you will be asked to: Please list specific changes you will make in your

practice as a result of the information you received from this activity.

Include specific strategies or changes that you plan to implement.THESE ANSWERS WILL BE REVIEWED.

ACG Virtual Grand RoundsJoin us for upcoming Virtual Grand Rounds!

Visit gi.org/ACGVGR to Register

Week 31, 2021Screening for Barrett’s Esophagus : Beyond Upper EndoscopyPrasad G. Iyer, MD, MS, FACGAugust 12, 2021 at Noon Eastern

Week 30, 2021Post‐ERCP Pancreatitis: Past, Present and FutureMohammad Yaghoobi, MD, FACGAugust 5, 2021 at Noon Eastern

3

4


3

Disclosures:

Speaker: C. Prakash Gyawali, MD, MRCP, FACGConsulting: Medtronic, Diversatek, Ironwood, Takeda, IsoThrive, Quintiles

Moderator: Amit Patel, MD, FACGDr. Patel, faculty for this educational event, has no relevant financial relationship(s) with ineligible companies to disclose.

*All of the relevant financial relationships listed for these individuals have been mitigated

ACG 2020 Clinical GuidelinesClinical Use of Esophageal Physiologic Testing

C. Prakash Gyawali, M.D.

Professor of Medicine

Division of Gastroenterology

July 2021

5

6


4

Objectives

1. Describe indications for currently available esophageal physiologic tests

2. Understand performance characteristics of esophageal physiologic tests

Initial Approach: History & Questionnaire

50

55

60

65

70

75

40 45 50 55 60 65 70 75

PCP history

RDQ

GI history

GERDQ

specificity

sens

itivi

ty

Jones R et al. APT 2009;30:1030-8Dent J et al. Gut 2010;59:714-21

Bolier EA et al. Dis Esophagus 2015;28:105-20Taft T et al. NGM 2016;28:1854-60

PPI trial, foregut symptom

PPI trial, troublesome

GERD symptom

BEDQ

Patient-reported symptom questionnaires may aid evaluation of patients with esophageal

symptoms, but symptom questionnaires alone should not be used to diagnose specific

esophageal conditions

Evaluation starts with a good clinical history

7

8


5

A

B

C

D

Gyawali CP, NGM 2012;24(Suppl1):2-4

HRM

UES and LES visible in the same window

Real time visualization of catheter positionCurled catheter can be identified and rectified

Three dimensional assessment of esophageal peristalsisIntuitive depiction of motor functionPatterns of abnormal motility can be easily recognized

Software tools can be used to assess sphincter functionVigor and timing of peristalsis can be assessed

Location of LES can be quickly identified for pH probe placement

HRM vs. Conventional Manometry

Improved diagnostic yield for achalasia compared to conventional manometry

Superior inter-rater agreement for motor diagnoses compared to conventional manometry

Learners favor HRM over conventional manometry

Roman S et al, Am J Gastroenterol 2016;111:372-80Carlson DA et al, Am J Gastroenterol 2015;110:967-77

Soudagar AS et al, Gut 2012;61:798-803

HRM is recommended for evaluation of obstructive esophageal symptoms without a

mechanical cause

HRM is recommended over conventional manometry

HRM

When to request a high-resolution manometry

Transit symptoms (dysphagia, regurgitation) not explained on EGD and/or barium swallow

Suspected esophageal motor disorder

As part of pH monitoring

Unexplained esophageal symptoms

Post fundoplication dysphagia

Dysphagia localized to upper esophageal sphincter

9

10


6

Adjunctive HRM Measures

z1

z2

Penagini R, Gyawali CP. J Clin Gastroenterol 2019;53:322-330Rogers B, Gyawali CP. Gastroenterol Clin North Am 2020;49:411-426

ImpedanceRapid Drink Challenge (RDC)Multiple Rapid Swallows (MRS) Utilization of supplementary/provocative

maneuvers with HRM improves the diagnostic yield of esophageal motility disorders in

patients with obstructive esophageal symptoms

DISORDERS OF PERISTALSIS

DISORDERS OF EGJ FUNCTION

10 wet swallows (supine/upright)

Abnormal median IRP

All swallows fail or premature

All swallows fail, no PEP

All swallows fail, 20% PEP

20% premature swallows

Alternate position swallowsRDC/MRS

Abnormal IRP persistsAbnormal RDC/MRS

Abnormal BE or FLIP

Achalasia type 1

Achalasia type 2

Achalasia type 3

EGJOO

Abnormal median IRP Abnormal RDC/MRS

20% premature swallows

All swallows fail, no PEP

20% hypercontractile

>70% ineffective and/or ≥50% failed

Absent contractility

DES

Hypercontractile

IEMNO EGJOO

NO DISORDER OF PERISTALSIS

Consider meal challenges if appropriate

Yadlapati R et al, CCv4.0, Neurogastroenterol Motil 2021

Y

Y

Y

N

N

N

Y

Alternate position swallowsRDC/MRS

N

N

Chicago Classification 4.0

11

12


7

Allen et al. Cleveland Clin J Med 2009;76:105-11O’Rourke AK et al, Otolaryngol Head Neck Surg 2016;154:888-91.

Blonski W et al, Am J Gastroenterol 2018;113:196-203

Barium Swallow

Indication:

Diagnosis of subtle rings or strictures

in the distal esophagus or

gastro-esophageal junction

HH=hiatus herniaT=13 mm barium

tablet

When to Order Barium Studies

Transit symptoms (dysphagia, regurgitation) without conclusive diagnosis after endoscopy, HRM

Follow up of symptomatic achalasia patients after therapy

Evaluation of esophago-gastric junction anatomy

Evaluation and management of complex strictures

Liquid Barium vs. 13 mm Barium PillBoth abnormal in 75% of achalasia patients

Abnormal pill swallow but normal barium swallow in 49% of EGJOOBoth normal in 61% of non-achalasia patients

Performance characteristics of barium esophagram for detection of esophageal dysmotility

Sensitivity: 0.69

Specificity: 0.50

Timed Upright Barium Swallow

Neyaz Z et al. J Neurogastroenterol Motil 2013;19:251-6;

8 oz of thin barium in upright positionNormal: no retention of barium in the esophagus

Abnormal: >5 cm barium column in 1 min>2 cm barium column in 5 min

Standardized, upright, timed barium esophagram protocol should be used when barium studies are performed for obstructive

symptomsBarium pill swallow provides additional valueBarium swallows can provide information on

esophageal clearance vs bolus retention

13

14


8

Diameter 6.3 mmCross sectional area: 30 mm2

Distensibility index:1.1

• Placed trans-orally during sedated upper endoscopy

• Positioned with 2-3 channels beyond the waist identified as the EGJ

• Step-wise volumetric distension from 20 to 70 ml

Stomach

16-cm

Functional Lumen Imaging Probe

Carlson D et al, Gastroenterology 2016Carlson D et al, AJG 2021 (in press)

Diameter 10.6 mmCross sectional area: 88 mm2

Distensibility index:5.8

Comparison of FLIP metrics (EGJ-DI, diameter) and HRM metrics

(IRP) to gold standard of esophageal emptying on timed upright barium swallow and/or

barium pill swallow in patients with dysphagia

sIRP15

uIRP12

DI2.0

Diameter13

sens 0.79 0.82 0.81 0.79

spec 0.61 0.55 0.76 0.85

AUC 0.79 0.79 0.84 0.88

FLIP 2.0: Panometry

Carlson D et al, Am J Gastroenterol 2016;111:1726; DDW 2018

When to order a FLIP study

Transit symptoms (dysphagia, regurgitation) not explained on EGD, HRM and/or barium swallow

Suspected esophageal motor disorder

Unexplained esophageal symptoms

Dysphagia despite myotomy, PD or POEM

Post fundoplication dysphagia

Evaluation of the pyloric sphincter

FLIP complements HRM for diagnosis of esophageal motility disorders

Patients in whom manometry cannot be completed Measurement of EGJ cross-sectional area or

distensibility during and following achalasia treatment

Measurement of cross-sectional area or distensibility to assess fibrostenotic remodeling in EoE

15

16


9

Dysphagia ± chest pain and bland regurgitationGERD symptoms not responsive to PPI therapy

Upper endoscopy

Normal Esophageal dilation, EGJ resistanceretained food, diverticulum

Mechanical obstruction/esophagitistreat appropriately

HRMPROVOCATIVE MANEUVERS

Vaezi MF et al, ACG Guidelines, Am J Gastroenterol 2020;115:1393-1411

Approach: Obstructive Pathway

TIMED UPRIGHT BARIUM RADIOGRAPH

SECOND OPINION ENDOSCOPY FUNCTIONAL LUMEN IMAGING PROBE

Gyawali CP et al, ACG Guidelines, Am J Gastroenterol 2020;115:1412-1428

DilateBotulinum toxin

ObserveBehavioral therapy

Definitive therapy

Reflux Symptoms: Definitions Are Important!

Refractory Heartburn

Heartburn not responding to stable PPI therapy over 12 weeks

Refractory GERD

Symptoms caused by reflux of gastric content not responding to stable PPI therapy over 12 weeks

Fass R, Sifrim D. Gut 2009;58:295-309Sifrim D, Zerbib F. Gut 2012;61:1340-54

Implication: symptoms may or may not be from reflux

Implication: symptoms are from inadequate management of reflux

Unproven GERD

Proven GERD

No GERD

17

18


10

Empiric PPI Therapy for Typical GERD

Jonasson C et al. APT 2012;35:1290-1300

Similar symptom relief

cost savings: €146/$160

Primary care referral: 347 pts

R

GERDQblinded

GERDQblinded

GERDQblinded

EGD/pH-metry

GERDQ GERDQ GERDQStratification

Rx

Rx

Rx

Rx

baseline 4 weeks 8 weeks

symptom basedn=174

test basedn=173

86.5%

80.1%

esophageal symptomsNNT for PPI response

Heartburn: 2Regurgitation: 5.6Chest pain: 4-7

Gyawali CP, Fass R. Gastroenterology 2018;154:302-318

Atypical and Extra-Esophageal Symptoms

Empiric Treatment

QD BID success$1972-4339

BID failure positive pH-impnegative HRM$3296-5721

BID failure negative pH-imp

positive HRM$2906-4880

BID failure negative pH-impnegative HRM$2773-4748

BID success$2998

Up-Front Testing

positive pH-impnegative HRMBID success

$3946

positive pHnegative HRM

BID failure$2581

negative pH-impnegative HRM

$877

negative pH-imppositive HRM

$1020

positive pH-impnegative HRM

surgical referral$1411

Carroll TL et al, Laryngoscope 2017;127:S1-13

Extra-Esophageal symptomsNNT for PPI response

Cough 11.4Hoarseness & sore throat 79.2

Gyawali CP, Fass R. Gastroenterology 2018;154:302-318

Up-front esophageal testing, preferably with pH-impedance monitoring off PPI and HRM, has value over laryngoscopy and empiric PPI trials for the evaluation of extra-esophageal

symptoms when GERD is suspected

19

20


11

Approach: Reflux PathwayReflux suspected

Esophagealheartburn

regurgitationchest pain

Extraesophagealcough

hoarsenesssore throat

UPPER GI ENDOSCOPYTo evaluate for conclusive reflux evidence

To evaluate for confounding diagnoses

Alarm symptomsLack of PPI response

treat as reflux?escalate management

conclusiveevidence

Unproven GERD

Proven GERD

obstructive symptomssuspicion for achalasia, motor disorders

motordisorder

Obstructive/atypical pathway

Obstructive/atypical pathway


Adkamar K et al, Gastrointest Endosc 1986;32:78-80Takashima T et al, Digestion 2012;86:55-58

Zagari RM et al, Gut 2008;57:1354-9

Yield of Endoscopy

Poh CH et al, Gastrointest Endosc 2010;71:28-34

0

10

20

30

40

erosiveesophagitis

Barrett'sesophagus

hiatus hernia stricture

PPI failure

no treatment

*

0

5

10

15

20

LA grade A LA grade B LA grade C LA grade D

* *

*p≤0.01105 with PPI failure, EGD on PPI91 with no treatment≥3 heartburn episodes a week

%Almost never seen in

asymptomatic controls

Seen in up to 8% of asymptomatic controls

LA Grade A LA Grade B

LA Grade C LA Grade D

Hill grade of EGJ on retroflexion

Hill LD et al, GIE 1996;44:541-4; Osman A et al, DDS 2021;66:151-5

I II

III IV

Endoscopy has high specificity but low sensitivity for findings of conclusive GERD

Bredenoord AJ et al, Neurogastroenterol Motil 2009;21:807-12

21

22


12

Reflux Monitoring

swallow acid reflux episode non-acid reflux episode

pH-impedance monitoring• higher sensitivity for detection of reflux episodes• higher potential for reflux-symptom association• acid reflux episodes become non-acid with PPI therapy

When to order ambulatory reflux monitoring

Esophageal symptoms persisting despite PPI

Prior to antireflux surgery or invasive GERD therapy

Persisting symptoms despite antireflux surgery

Symptoms following LES disruption, e.g., myotomy, POEM

Investigation of belching and regurgitation syndromes

Acid Exposure Time (AET)Cumulative time pH<4 as a percentage of the duration of recording

Abnormal pH PatternsReflux episodes

heartburn2 min

Reflux-symptom correlation

23

24


13

18.8 Schindlbeck 1987

Kasapidis 1993 3.9

13.6 Mattioli 1989

Vitale 1984 7.2

Johnsson 1987 3.4

Masclee 1990 4.0

Esophageal acid exposure (% time pH<4.0)

Upper limit of normal

Richter 1992 5.8Mattioli 1989,,Smout 1989 5.0

Schindlbeck 1987 7.0

GERD with esophagitis (mean)

9.6 Vitale 1984

12.6 Masclee 1984

27.6-29.8 Mattioli 1989

31.7 Kasapidis 1993

Kahrilas & Quigley Gastro 1996;110:1982-96

10.2 Schindlbeck 1987

6.4 Masclee 1984

11.6 Kasapidis 1993GERD without esophagitis (mean)

4.0

6.0

4.9 Ayazi 20094.4 Wenner 2005

5.9 Pandolfino 20035.8 Vitale 1984

Wireless pH monitoring

pH thresholds are partly based on evidence, but mostly arbitrary and based on consensus

agegender

study off PPI

typical symptoms

abnormal AET*

abnormal RET

SAP (acid reflux)

SAP (all reflux)**

number of reflux events

0 1 2 3 4 5 6

Predictors of GERD Symptom ImprovementpH-impedance in a ‘real world’ setting

Patel A, Sayuk GS, Gyawali CP. CGH 2015;13:884-891.

*p=0.002-0.014**p=0.026-0.05

n=18753.8±0.9 yrs

70.6% female

50.3% tested off PPI61% typical symptoms39.9 ±1.3 mo follow-up

GLOBAL SYMPTOM SEVERITY (GSS) CHANGE

0

20

40

60

8076

69

57

47

Strong Good RH Equivocalp<0.001 across groupsAET+/SAP+ AET+/SAP- SAP+ neither

Abnormal acid exposure time (AET) is a predictor of symptom improvement following

GERD management, including antirefluxsurgery

25

26


14

Clinical Value of Prolonged pH Monitoring

NERD

Penagini R et al, J Neurogastroenterol Motil 2015;21:265-72

50 patients 35 patients

Symptom Response to Antireflux Therapy

NERD: 77%FH: 45%

Diagnosis may shift to non-erosive reflux disease when prolonged pH monitoring is utilized

Clinical Value of Prolonged pH MonitoringGERD symptoms

with incomplete response to PPIn=142

EGD off PPI96-hour wireless pH monitoring

n=128

Able to discontinue PPIn=34 (34.0%)

AET 6.6 [SD 3.6]*80% with ≥2 days abnormal AET*

Completed studyn=100

Unable to discontinue PPIn=66 (66.0%)

AET 4.3 [SD 3.6]*67% with 0 days abnormal AET*

RESQ-eD 17.8 [SD 11.7]*GERDQ 9.3 [SD 4.6]*

RESQ-eD 12.0 [SD 9.6]*GERDQ 7.2 [SD 3.0]*

Yadlapati R, Masihi M, Gyawali CP, et al. Gastroenterology 2021;160:174-182

Stopping PPI with 0 vs 4d of AET<4.0% OR 10 (95% CI 2.70-43.32), p<0.01

Continuing PPI with ≥2d of AET>4.0%OR 5.31 (95% CI 2.91-13.44), p<0.01

*p<0.05

14 did not meet inclusion criteria12 had EoE

3 had advanced grade esophagitis7 had insufficient reflux monitoring time

6 were lost to follow up

Physiologic AET on multiple consecutive days rules out pathologic GERD and allows PPI discontinuation

27

28


15

Newer Metrics: Markers of Longitudinal Injury

Kessing et al, Am J Gastroenterol 2011;106:2093-7

Baseline Mucosal Impedance

Impedance signature of a bolus passing across a pair of sensors

baseline impedance

Patel A, Gyawali CP et al, APT 2016

Pearson’s r= -0.5

acid exposure time25 20 15 10 5 0

dist

al M

NB

I

CONCLUSIVE EVIDENCE FOR PATHOLOGIC REFLUX

EVIDENCE AGAINST PATHOLOGIC REFLUX

BORDERLINE OR INCONCLUSIVE EVIDENCE

ENDOSCOPY pH or pH-IMPEDANCE

ADJUNCTIVE OR SUPPORTIVE EVIDENCE*

LA grades C&D esophagitisLong segment Barrett’s mucosa

Peptic esophageal stricture

HRM

LA grades A&B esophagitis

Histopathology (score)Electron microscopy (DIS)Low mucosal impedance

AET>6%

AET<4%Reflux episodes<40

AET 4-6%Reflux episodes 40-80

Reflux-symptom associationReflux episodes>80

Low MNBILow PSPWI

Hypotensive EGJHiatus hernia

Esophageal hypomotility

*factors that increase confidence for presence of pathologic reflux when evidence is otherwise borderline or inconclusive

Gyawali CP et al, Lyon Consensus, Gut 2018

Ambulatory reflux monitoring is superior to history, questionnaires, PPI trial and

inconclusive endoscopy for the diagnosis of pathologic GERD

Ambulatory reflux monitoring is performed off PPI in patients without prior conclusive

evidence for GERD

29

30


16

Subsequent ApproachReflux suspected

Esophagealheartburn

regurgitationchest pain

Extraesophagealcough

hoarsenesssore throat

UPPER GI ENDOSCOPYTo evaluate for conclusive reflux evidence

To evaluate for confounding diagnoses


?other diagnosestreat as functional

negative

Alarm symptomsLack of PPI response

negative or equivocal evidence

equivocal evidence


conclusiveevidence

ADJUNCTIVE METRICSbaseline impedance, PSPW, mucosal integrity, HRM

conclusiveevidence

AMBULATORY REFLUX MONITORINGTo evaluate for conclusive reflux evidence

Unproven GERD

Proven GERD

Proven GERD

No GERD

negative GERD less likelyGERD likely positive

Wireless pH vs. pH-Impedance Testing

Wireless pH (off PPI)

• Catheter intolerance

• Infrequent symptoms, needing reflux-symptom association

• High clinical suspicion of GERD with negative 24-hour reflux monitoring

• Very low clinical suspicion of GERD

pH-impedance (off PPI, rarely on PPI)

• Refractory typical or atypical symptoms in patients with proven GERD (on PPI)

• Respiratory symptoms or cough in patients with pulmonary disease (off PPI)

• Repetitive belching in patients with and without reflux symptoms (off PPI)

• Suspicion of rumination syndrome (off PPI)

• Persistent reflux or increased belching following antireflux procedures (off PPI)

• High pre-test likelihood of GERD, prior to invasive antireflux procedures

• Investigation of persisting reflux symptoms despite empiric PPI trial

Either option (off PPI)

Sifrim D, Gyawali CP. Am J Gastroenterol 2020;115:1150-1152

31

32


17

Using Pre-Test Probability of RefluxTypical Symptoms

heartburnExtra-Esophageal Symptoms

cough hoarseness

asthmaNo response to BID PPI

HAs-BEER toolHeartburn=1Asthma=1BMI>25=1Cough=0

Hoarseness=0

HAs-BEER toolscore of 3:

97.8% sensitivity for AET>5.5%92% positive predictive value

HAs-BEER toolscore of ≤2

80% negative predictive value

pH monitoring off PPIProlonged wireless pH monitoring

pH-impedance monitoring on PPIReflux episodes, non-acid reflux

Patel DA….Vaezi MF et al, Gastroenterology 2018;155:1729-40

<10% of atypical

symptoms

0

5

10

15

20

25

30

35

pre intervention offPPI

pre intervention onPPI

post intervention 6months

post intervention 12months

BID PPI arm

MSA arm

*

GE

RD

HR

QL

scor

e

*

Reflux Episodes Predict GERD Response

Sen

sitiv

ity

1-Specificity

Satisfaction with therapy GERD HRQL

sensitivity 0.64 specificity 0.67 AUC 0.76

sensitivity 0.64 specificity 0.59 AUC 0.71

Rogers BD….Crowell M, Vela MF et al, Gut 2020 (in press)

Randomized Study Comparing BID PPI to MSA

Refractory regurgitation123 patients

age 46.9±1.2 yr43% female

35 reflux episodes 35 reflux episodes

MSA: magnetic sphincter augmentation

>80 reflux episodes pre-crossover to MSApredicted improvement from MSA

Magnetic sphincter augmentation device

33

34


18

AETReflux episodes

40 reflux episodessensitivity 0.80specificity 0.51

AUC 0.70

AET 0.5%sensitivity 0.62specificity 0.51

AUC 0.58

Healthy volunteers given BID PPI

European heartburn-predominant cohortn=43

Patients with proven GERDtreated with BID PPI

n=66

North American regurgitation-predominant cohort n=42

pH-impedance monitoring on

BID PPI

Median values in healthy volunteers

median AET 0.0% median reflux episodes 16 median 5 cm MNBI 2400 ohms

Gyawali CP….Sifrim D et al, Gastro 2021 (in press)

Studies ‘on PPI’

AET>4%AET<0.5%

episodes<40

10 4 0 10 4 14

3 10 4 19 2 2

14 patients

2 patients

Abnormal reflux burden and/or abnormal mucosal integrity Parameters based on new thresholds Normal study

Heartburn-Predominant

EuropeanCohort

Regurgitation-Predominant

North AmericanCohort

cumulative n

cumulative n

n

n

Total 14 patients (32.6%)

Total 17 (40.5%) patients

1

2

Hypervigilance

Total 1 patient (2.3%)



Total 21 (50.0%) patients

10 with AET>4%; 7 with episodes>80; 5 with MNBI<1500 ohms; 2 with episodes 40-80;

4 with RSA; 14 with PSPW index <50%

3 with AET>4%; 12 with episodes>80; 9 with MNBI<1500 ohms; 9 with episodes 40-80; 10

with RSA

10 with episodes 40-80; 8 with AET 0.5-4%; 2 with RSA; 13 with

PSPW index <50%

19 with episodes 40-80; 13 with AET 0.5-4%; 12 with RSA

Escalate reflux management Escalate reflux managementif other supportive features

e.g. hiatus hernia

Neuromodulators

GERD Evidence: Studies ‘on PPI’

Gyawali CP….Sifrim D et al, Gastro 2021 (in press)

57.1% non-responders 28.6% non-responders 100% NR 71.4% R

82.4% non-responders 81.0% non-responders 50% NR 50% R

RSA: reflux-symptom association

MNBI<1500episodes>80 episodes 40-80 AET 0.5-4% RSA

Overall 79% Heartburn 60%

Regurgitation 83%

Response to Surgical Management

Overall 85% Heartburn 60%

Regurgitation 93%

In patients with proven GERD, ambulatory reflux monitoring performed on PPI therapy can be useful in identifying persistent GERD that might benefit from surgical management

35

36


19

Role of HRM in GERD

Chan WW et al, Surg Endosc 2011;25:2943

1.0-2.5% of ‘GERD’ referred for anti-reflux

surgery

Predictors of post-fundoplication dysphagia Univariate Multivariate

n=157, 2.1 yr follow up OR 95% CI OR 95 % CI

Age (years) 0.99 0.96, 1.02 0.97 0.92, 1.02

Gender (F) 2.10 0.75, 5.92 1.12 0.25, 4.95

Pre-fundoplication dysphagia 2.95 1.25, 6.98 1.15 0.34, 3.87

Early post-fundoplication dysphagia 3.10 1.23, 7.76 1.40 0.34, 5.83

Dysmotility on post-fundoplication barium swallow

2.17 0.89, 5.24 1.43 0.19, 10.67

Recurrent Hernia on barium swallow 3.45 1.12, 10.63 3.37 0.36, 31.50

Absent contraction reserve 3.37 1.12, 10.59 3.73 1.11,12.56

In patients with persistent reflux symptoms, HRM rules out motor disorders, and assesses

esophageal peristaltic performance

TYPE 2

TYPE 1

TYPE 3

TYPE 3DIAPHRAGM NOT TRAVERSED

0

40

80

0

40

80

0

40

80

Reflux burden: █ normal █ abnormal

Pandolfino JE, et al. Am J Gastroenterol 2007; 102:1056-63Rengarajan A, Gyawali CP. J Clin Gastroenterol 2020;54:22:27

Rogers BD et al. Neurogastroenterol Motil 2020

Healthy controlsn=484

GERD patientsn=482

97.1% 61.8%

2.9% 25.9%

0 12.2%

HRM complements EGD and barium studies in increasing diagnostic yield of hiatus hernia

Tolone et al, UEG Journal 2018

HRM had sensitivity of 94.3% and specificity of 91.5% in detecting hiatus hernia using hernia size at surgery as gold standard compared to endoscopy (96.2%, 74.5%) andbarium radiography (69.8%, 97.9%)

37

38


20

LES level

Crural level

Barium Radiography20 patients with reflux symptoms50% had ‘reflux’ on esophagramGold standard: pH impedance

Saleh CMG et al, NGM 2015;27:195-200

sensitivity 46%specificity 44%PPV: 50%, NPV: 40%

Reflux observed during barium studies cannot be used as evidence supporting pathologic

reflux

REFRACTORY REFLUX SYMPTOMSDESPITE PPI THERAPY

PROVEN GERDREFRACTORY GERD SYMPTOMS

LA Grades C/D EsophagitisBarrett’s Esophagus >1 cmPeptic StrictureAcid Exposure Time >6%

ENDOSCOPYHIGH RESOLUTION MANOMETRY

pH OR pH IMPEDANCE MONITORING OFF PPI

ENDOSCOPYHIGH RESOLUTION MANOMETRY

pH IMPEDANCE MONITORING ON PPI**

GERD EVIDENCE*

REFRACTORY GERDPersistent Acid Reflux

Persistent Weakly-Acid Reflux

NO GERD EVIDENCE*NO ONGOING

GERD EVIDENCE*

*according to Lyon Consensus criteria

Persistent symptoms

Repeat endoscopy and high-resolution manometry on case-by-case basis

**pH impedance on PPI not essential in patients with large hiatal hernia and proven GERD with refractory GERD

symptomsZerbib F et al, Neurogastroenterol Motil 2020

UNPROVEN GERD

GERD EVIDENCE*

39

40


21

‘r’ wave

Other Mimickers of Esophageal SymptomsPost prandial study: monitoring for 30-90 min following a meal

Rumination Syndrome

Yadlapati R et al, Clin Gastroenterol Hepatol 2018;16:211

Transient LES RelaxationSupragastric Belching

0

20

40

60

Rumination Reflux Supragastricbelching

Normal

n=94 PPI non-responders

>6 TLESR/hr

≥1 episode/hr

>2 episodes/hr

Supragastric Belching

Inter-rater Comparison of Diagnosis of a Behavioral Disorder

Supragastric Belching, Rumination

3 raters, 22 pH-impedance and PP HRIM studies

Inter-rater agreement was higher for pH-impedance monitoring

Diagnostic yield was higher for post prandial HRIM

Inter-rater agreement is higher when clinical context was provided

Delay K et al, Neurogastroenterol Motil 2021;e14106

pH-impedance monitoring can be used for investigation of excessive belching

Post-prandial HRIM can be used for investigation of suspected rumination

41

42


22

HIGH RESOLUTION MANOMETRY, HIGH RESOLUTION IMPEDANCE MANOMETRYto rule out obstructive disorders, major motor disorders, achalasia

PROVOCATIVE HRM:ATYPICAL/BEHAVIORALstandardized test meal, post prandial monitoring

ENDOSCOPY to evaluate and treat mucosal and mechanical processes

Atypical-Behavioral Pathway


AMBULATORY REFLUX MONITORINGTo evaluate for conclusive reflux evidence and behavioral syndromes

Proven GERD

GERD + Behavioral

Behavioral syndrome

Neither, Functional

Evaluation of Esophageal Symptoms

Esophageal symptoms

Symptom Improvement

Characterize symptoms

Apply appropriate testing

Analyze and interpret test results

Choose appropriate management

Lyon Consensus 1.0

Chicago Classification 4.0

Other criteriaPast investigation

Past treatment

Overlap between disorders

Phenotype esophageal disorders

43

44


23

Take Home Points

• Start with a good history, which can direct investigation

• EGD, HRM, barium esophagram and FLIP, usually performed in sequence, leads to a diagnosis of obstructive symptoms

• PPI trial is a reasonable starting point for typical reflux symptoms

• Up front esophageal testing is cost effective for atypical symptoms

• Concept of unproven vs. proven GERD determines reflux monitoring off vs. on PPI therapy; interpretation paradigms differ

• Behavioral syndromes are diagnosed using pH-impedance monitoring and post prandial HRIM

Birthplace of High-Resolution ManometrySt. Louis, Missouri, USA

45

46


24

Questions?

Speaker: C. Prakash Gyawali, MD, MRCP, FACG

Moderator: Amit Patel, MD, FACG

47

48


Participating in the Webinar

Documents