update on esophageal motility testingtnms.org.tw/news/pdf/128643907_249.pdfupdate on esophageal...

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


(IRP = 27.1 mmHg)

Pan esophageal pressurization

0 150 mmHg


(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

)


(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


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


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


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


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)





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








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








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

http://gastro.wustl.edu/introduction/introduction.html

http://www.medicine.wustl.edu/

update on esophageal motility testingtnms.org.tw/news/pdf/128643907_249.pdfupdate on esophageal...

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