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TRANSCRIPT
Update on Esophageal Motility Testing
C. Prakash Gyawali, M.D.
Professor of Medicine
Division of Gastroenterology
Hualien
May 2018
Disclosures: Medtronic (consulting, speakers’ bureau), Diversatek, Reckitt Benckiser (speakers’ bureau); Ironwood, Torax, Quintiles (consulting)
THE BASICS
INDICATIONS
CLINICAL VALUE
Conventional Esophageal Manometry
1
2
3
4
5
A
B
C
D
Gyawali CP, NGM 2012;24(Suppl1):2-4
• UES and LES visible in the same window
• Diaphragm traversed
• A few (ideally 3) sensors in the stomach
Time (s)
5 s
SWALLOW
B
1
5
10
15
20
25
30
35
100
50
0
150
mmHg
20 Le
ngth
alo
ng th
e e
so
ph
agus (
cm
)
Positive Intra-abdominal pressure
5 s
INSPIRATION
A
Negative intra-thoracic pressure Esophageal contraction
Curling
Gyawali et al, Neurogastroenterol Motil 2013
Diaphragmatic contraction
EGJ
EGJ
gastric pouch
Butterfly or Mirror Image pattern
Catheter Positioning
I I I I E E E E
LES LES
LES
?LES?
?LES?
D D
Normal EGJ Small HH Large HH LES not traversed
Roman S et al, CGH 2011;9:1050-5
Gyawali CP, CGH 2011;9:1015-6 I=inspiration; E=expiration; D=diaphragmatic crural contraction
Type I EGJ Type II EGJ Type III EGJ Pandolfino J et al, AJG 2007; 102:1056
Problem Potential Solutions
Inability to traverse LES Patient stands up
Patient raises hands above head
Operator inserts 45-90° twist on catheter
Patient takes repeated gulps of water
Placement under endoscopic guidance
Inability to traverse diaphragm Patient stands up
Placement under endoscopic guidance if deemed
absolutely necessary
**critical imperfection**
0.02% of 2000 studies
mostly achalasia
diagnosed accurately in 93%*
non-critical imperfection
0.03% of 2000 studies
almost all large hiatus hernias
*using clinical context, other studies Roman S et al, CGH 2011;9:1050-5
Gyawali CP, CGH 2011;9:1015-6
Swallow Artifacts
WET SWALLOW DRY SWALLOW DOUBLE SWALLOW BELCH
TRANSIENT LES RELAXATION
REJECT:
Dry swallows
Double swallows
Swallows less than 20-30 s apart
Swallows close to belch, TLESR, cough, gag
Operator Roles • Explain the procedure
• Engage the patient
• Reassurance
Problem Solution
Inability to traverse nasal passage Topical lidocaine gel
Nasal decongestant spray
Gagging, repeated swallowing, belching Reassurance
Relaxation exercises
Deep breathing
Patient opens mouth
Patient watches Clouse plots
Patient squeezes soft ball or toy
Patient concentrates on focal point
1Roman S et al, CGH 2011;9:1050-5 2Patel A et al, NGM 2014
Gyawali CP, CGH 2011;9:1015-6
12% of 2000 patients1
10% of 366 patients2
Swallow Complement
• <7 evaluable swallows in 12% of 2000 studies
– Catheter intolerance
– Achalasia
– Previous foregut surgery
• 10 supine swallows vs. first 5 supine swallows (n=148)
– Overall agreement = 0.814, p<0.001
– No achalasia was missed
– Change in diagnosis in 4% (from weighting of abnormal swallows)
– Change in sub-classification in 13%
Roman S et al, CGH 2011;9:1050-5
Xiao Y et al, NGM 2012;24: e489-496
Standard protocol: 10 test swallows 20-30 s apart
ambient temperature water
THE BASICS
INDICATIONS
CLINICAL VALUE
Indications for Manometry
Accepted indications
Transit symptoms not explained by endoscopy and/or barium studies
Suspicion of major motor disorders (especially achalasia)
Assessment of esophageal peristaltic performance
Assessment of unexplained esophageal symptoms
Diagnosis of rumination syndrome and supragastric belching
Evaluation of post fundoplication dysphagia
Diagnosis of functional esophageal disorders (by exclusion of major motor disorders)
Localization of the LES for appropriate placement of pH and pH-impedance catheters
Emerging indications
Assessment of morphology and integrity of the esophagogastric junction
Measurement of hiatus hernia size
Assessment of esophageal peristaltic performance prior to bariatric procedures
Savarino E, Roman S, Gyawali CP, et al., Nature Reviews Gastroenterol Hepatol 2017 14:665-676
What HRM Classifications Provide
– Uniformity in designation of motor disorders
– Basis for future research of esophageal physiology and
pathophysiology
– Characterization of HRM findings in non-structural dysphagia or
esophageal chest pain (Chicago Classification)
– Definition of esophagogastric junction and esophageal body motor
patterns that may explain pathophysiologic mechanisms in GERD
(GERD Classification)
THE BASICS
INDICATIONS
CLINICAL VALUE
TRANSIT
IRP
Integrated Relaxation Pressure
Key Determinant of EGJ Transit
IRP
contractile pressure
intrabolus pressure
pressure gradient
gastric
baseline
IRP specific to HRM system
Median vs. mean IRP
Achalasia with normal IRP
Gyawali CP et al, Neurogastroenterol Motil 2013;25:99; Kahrilas PJ et al, Neurogastroenterol Motil 2015;27:160
0
5
10
15
20
25
30
35 5 s
No pressurization
Impaired EGJ relaxation
(IRP = 16.3 mmHg) 5 s
DL = 3.2 s
5 s
100
50
0
150
mmHg
30
Le
ng
th a
lon
g th
e e
so
ph
ag
us (
cm
) A B C
0 150 mmHg
Impaired EGJ relaxation
(IRP = 27.1 mmHg)
Pan esophageal pressurization
0 150 mmHg
Impaired EGJ relaxation
(IRP = 25.7 mmHg)
0 150 mmHg
achalasia type 1 achalasia type 2 achalasia type 3
5 s Impaired EGJ relaxation
(IRP = 18.4 mmHg)
DL = 6.0 s
0
5
10
15
20
25
30
35
Le
ng
th a
lon
g th
e e
so
ph
ag
us (
cm
)
Impaired EGJ relaxation
(IRP = 21.3 mmHg)
5.0 s Distal pressurization
D E
0 150 mmHg 0 150 mmHg
5 s
Distal pressurization
EGJOO EGJOO
1. LES pseudorelaxation
2. Effect of opioids
3. Effect of structural lesions
4. Achalasia vs absent contractility
Gyawali CP, Neurogastroenterol Motil 2016
Potential Pitfalls and Caveats
IRP 3.5 mmHg
IRP 40.2 mmHg
161 chronic opioid users
66 studied on opioids
55 studied off opioids
Gastric lap band
Ratuapli SK et al, Am J Gastroenterol 2015;110:979-84
Esophageal Body Diagnostic Tools
duration
length amplitude
DCI 450-8000 mmHg.cm.s DL <4.5 s
Hypercontractile disorder
Jackhammer esophagus
Ineffective peristalsis
Diffuse esophageal spasm
Distal Contractile Integral Distal Latency
Kahrilas PJ et al, Neurogastroenterol Motil 2015;27:160
fragmented ineffective
break: 6.2 cm
DCI: 730 mmHg.cm.s DCI: 396 mmHg.cm.s
intact failed
DCI: 0 mmHg.cm.s DCI: 2048 mmHg.cm.s
Spectrum of Hypomotility
Spectrum of Hypermotility
DCI : 11,059 mmHg-s-cm
hypercontractile
6.6 s CDP
3.1 s
premature
IRP >ULN
100% failed peristalsis
or spasm
IRP >ULN
not type I-III achalasia
IRP normal
short DL or
high DCI or
100% failed peristalsis
Achalasia
Type I: no contractility
Type II: ≥20% PEP
Type III: ≥20% spasm (DL<4.5))
EGJ outflow obstruction
Incompletely expressed achalasia
Mechanical obstruction
DES
≥20% premature (DL<4.5))
Jackhammer esophagus
≥20% DCI>8000 mmHg.cm.s
Absent contractility
No measurable contraction
EGJ obstruction
Major disorders
not seen in normal
subjects
yes
yes
yes
no
no
PEP: panesophageal pressurization Kahrilas PJ et al, Neurogastroenterol Motil 2015;27:160
Major Motor Disorders
Marin I & Serra J, NGM 2016;28:543-53
Ang D et al, NGM 2017; in press
Provocative Maneuvers
83% 14%
3%
Rapid Drink Challenge: 100-200 mL water
pre
ssu
re g
rad
ien
t acro
ss E
GJ
Rapid Drink Challenge
identifies outflow obstruction
Provocative Maneuvers Standardized Test Meal: 200 g soft cooked rice or cheese & onion pasty
Ang D et al, Lancet Gastroenterol Hepatol 2017;2:654-61
0
10
20
30
40
50
60
70
Water swallows Test meal
Any dysmotility
Major disorder
Minor disorder
n=750
*p<0.05 compared to test meal
*
*
*
High Resolution Impedance
Manometry (HRIM, HRM-Z)
Lin Z et al, Am J Physiol Gastrointest Liver Physiol 2014;307:G437-44
Nadir impedance
Pressure at nadir impedance = intrabolus pressure
z1
z2
z2:z1 ratio: EII
EII: esophageal impedance integral
Achalasia Type II
IRP= 24.2 mmHg
air
liquid EGJ
Impedance-Pressure Topography Assessing Bolus Retention without Radiation
Image courtesy: John Pandolfino
100
50
0
150
mmHg
30
Impedance Bolus Height (IBH)
Cho YK et al, Am J Gastroenterol 2014; 109:829-35
Pandolfino JE et al, Neurogastroenterol Motil 2013;25:496-e368
Carlson D et al, Gastroenterology 2015;149:1742-51
Future Directions:
Functional Lumen Imaging Probe
50% (17/34) patients with ‘normal’ HRM
had an abnormal response to distension
on FLIP topography
FLIP topography
TRANSIT Identify disorders associated with abnormal esophageal transit
Define esophageal outflow obstruction syndromes
Define spastic and hypercontractile disorders
Define extreme hypomotility
REFLUX
EGJ Barrier Function
corrected for respiratory cycles:
EGJ-CI in mmHg.cm
duration
len
gth
amplitude
1 a
EGJ Contractile Integral (EGJ-CI)
Gor P et al, Dis Esophagus 2016
Tolone S et al, Neurogastroenterol Motil 2015
EGJ Morphology Distance from nares (cm)
TYPE 1
TYPE 2
TYPE 3
Pandolfino JE, et al. Am J Gastroenterol 2007; 102:1056-63
Gyawali CP, et al., GERD Consensus document, Neurogastroenterol Motil 2017 ;29:epub
type 1
type 2
type 3
1 b
fragmented ineffective
break: 6.2 cm
DCI: 730 mmHg.cm.s DCI: 396 mmHg.cm.s
intact failed
DCI: 0 mmHg.cm.s
DCI: 2048 mmHg.cm.s
Esophageal Body 2
Normal Fragmented Ineffective Absent Body
gradient of reflux burden
Esophageal hypomotility is associated with increased reflux burden
Gyawali CP, et al., GERD Consensus document, Neurogastroenterol Motil 2017 ;29:epub
Contraction Reserve
DCI MRS DCI
MRS DCI>DCI wet swallows normal response:
Stoikes N, et al, Surg Endosc 2012
Shaker A, et al, Am J Gastroenterol 2013
Multiple Rapid Swallows: 5 rapid swallows of 2 mL water
3
Evaluate EGJ
intact
Evaluate esophageal body
hypotensive
hiatus hernia
both hypotensive & hiatus hernia
intact
fragmented peristalsis
ineffective esophageal motility
absent contractility
Evaluate contraction reserve contraction reserve
no contraction reserve
Possible diagnoses
Gyawali CP, et al., GERD Consensus document, Neurogastroenterol Motil 2017 ;29:epub
1
2
3
GERD Classification:
Hierarchical Approach
Provocative Maneuvers Multiple Rapid Swallows: 2 mL water x 5 rapid swallows
Normal
Contraction
reserve
No contraction
reserve
wet swallow MRS implications
normal response
low likelihood of future IEM
IEM may resolve after ARS
low likelihood of post ARS motor dysphagia
IEM may persist or develop after ARS
high likelihood of post ARS motor dysphagia
Shaker A, Gyawali CP, et al, Am J Gastroenterol 2013;108:1706
Mello M, Gyawali CP, et al, Neurogastroenterol Motil 2015 (in press)
TRANSIT Identify disorders associated with abnormal esophageal transit
Define esophageal outflow obstruction syndromes
Define spastic and hypercontractile disorders
Define extreme hypomotility
REFLUX Identify disruption of the esophagogastric junction
Describe esophageal hypomotility syndromes associated with abnormal clearance
Evaluate contraction reserve
UNEXPLAINED FOREGUT SYMPTOMS
Rumination Syndrome
‘r’ wave
Supragastric Belching
Kessing B et al, Am J Gastro 2014;109:1196-1203
Behavioral disorder with air rapidly brought into the esophagus,
then expelled, often loudly and repetitively
Riehl ME et al, Dis Esophagus 2016;29:490-6
gastric belching
TRANSIT Identify disorders associated with abnormal esophageal transit
Define esophageal outflow obstruction syndromes
Define spastic and hypercontractile disorders
Define extreme hypomotility
REFLUX Identify disruption of the esophagogastric junction
Describe esophageal hypomotility syndromes associated with abnormal clearance
Evaluate contraction reserve
UNEXPLAINED FOREGUT SYMPTOMS Diagnose rumination syndrome
Evaluate for supragastric and gastric belching
Normal Manometry
Bill J, Rajagopal S, Kushnir V, Gyawali CP. Dis Esophagus 2018 ; in press
2.3%
822 EGD’s for dysphagia in 694 patients
The most common motor pattern in GERD
TRANSIT Identify disorders associated with abnormal esophageal transit
Define esophageal outflow obstruction syndromes
Define spastic and hypercontractile disorders
Define extreme hypomotility
REFLUX Identify disruption of the esophagogastric junction
Describe esophageal hypomotility syndromes associated with abnormal clearance
Evaluate contraction reserve
UNEXPLAINED FOREGUT SYMPTOMS Diagnose rumination syndrome
Evaluate for supragastric and gastric belching
NORMAL ESOPHAGEAL PHYSIOLOGY
Despite limitations, with meticulous technique, important
diagnoses like achalasia are rarely missed with HRM
An informed and astute operator increases likelihood of
a technically sound study
Understanding of esophageal pathophysiology, and
attention to presenting symptoms improves overall
clinical value of motility testing
New advances will enhance the value of motility testing,
especially when HRM is not conclusive
Birthplace of High Resolution Manometry
St. Louis, Missouri, USA