APPROACH TO
ESOPHAGEAL
MOTILITY
DISORDERS
HIGH RESOLUTION MANOMETRY BASICS
BASICS OF IMPEDANCE AND FLIP PANOMETRY
ESOPHAGEAL MOTILITY DISORDER CLASSIFICATION BASED ON MANOMETRY
MANAGEMENT OF ACHALASIA CARDIA
PHENOTYPE BASED MANAGEMENT OF ESOPHAGEAL MOTILITY DISORDERS
HIGH RESOLUTION MANOMETRY
TECHNIQUE
Transnasal intubation
In HRM, once the manometric catheter is positioned across the EGJ, no further repositioning is required.
Simultaneous assessment of sphincters and body with a single series of swallows is possible with the catheter
in a single, fixed position.
The data acquisition period with HRM also tends to be shorter than with conventional manometry, possibly
increasing study acceptability and tolerability among patients.
PROTOCOL
Once the manometric catheter is positioned, the patient undergoes a 10-swallow protocol in the supine
position consisting of 10 swallows, each using 5 mL of water.
Although upright and provocative swallows with viscous and solid food challenges can be added to the
basic protocol, there are currently few validated metrics to determine the significance of swallow
patterns associated with these challenges
ANATOMIC PARTS OF THE
HRM 3D PLOT
CONTRACTILE SEGMENTS
Esophageal peristalsis consists of a progressive sequence
of segmental contractions demarcated by three pressure
troughs (proximal, middle, and distal)
The first contractile segment is continuous with the
pharyngeal and UES contraction
The second and third contractile segments, comprising
most of the tubular esophagus, are not always distinct
and sometimes merge as a seamless contraction.
Fourth contractile segment is the LES.
TRANSITION ZONE
A stereotypical morphologic feature of peristalsis is the major pressure trough between the
first and second contractile segments, alternatively labeled the "transition zone”.
Physiological studies have concluded that this is the region of transition from central nervous
system (CNS) control of peristalsis to enteric nervous system (myenteric plexus) control.
Transition zone defects may be related to dysphagia in a small percentage of patients (<4
percent)
TYPES OF PERISTALSIS
Primary
Secondary
Tertiary
HRM REVOLVES AROUND 3
MAIN PARAMETERS
IRP
DCI
DL
IRP – INTEGRATED RELAXATION PRESSURE
IRP is a measure for assessing the adequacy of EGJ
relaxation with swallowing.
Abnormal deglutitive LES relaxation is the most
fundamental abnormality of esophageal motility.
IRP is defined as the average minimum EGJ pressure for
four seconds of relaxation (contiguous or noncontiguous)
within 10 seconds of swallowing (upper sphincter
relaxation).
The published upper limit of normal for the IRP is 15
mmHg which represents the 95th percentile
DISTAL LATENCY
Distal latency (DL) is a measure of peristaltic timing
and is dependent on the integrity of deglutitive
inhibition rather than peristaltic velocity.
DL- Interval between UES relaxation and the CDP.
Contractions are defined as premature or of normal
latency.
In normal subjects, the median DL is 6.2 seconds with a
minimal value of 4.6 seconds, thereby establishing 4.5
seconds as the lower limit of normal
CONTRACTILE DECELERATION POINT
The contraction deceleration point (CDP) demarcates
the proximal region in which the conduction
(peristaltic) velocity is fast from the distal region
where propagation is slow, reflecting the progression
of ampullary emptying
The CDP location Defining the intersection point
between two tangent lines of the 30 mmHg isobaric
contour: one extending distally from the transition
zone and the other extending proximally from the
EGJ when it reestablishes its normal postdeglutitive
position
Added criterion is that the CDP is localized within 3
cm of the proximal margin of the EGJ
DISTAL CONTRACTILE INTEGRAL
A composite of the mean distal contractile amplitude,
length of the distal esophagus, and contractile duration.
DCI is measured proximal to distal pressure troughs.
A box is constructed to delineate the contractile activity
relegated to the second and third contractile segments
The DCI is then calculated by summing the pressure
measurements at each enclosed coordinate.
To exclude the effects of vascular
artifacts and/or intrabolus pressure in the DCI
computation, the first 20 mmHg is discounted.
Therefore, the DCI value is greater than zero only when
foci of intra-esophageal pressure exceed 20 mmHg.
CONCEPT OF IMPEDANCE
Purple – fluid
Blue – air
Empty - white
FLIP PANOMETRY
The EndoFLIP EF-325N measurement probe consists of
a polyutherane balloon mounted on the distal 14 cm of a
plastic catheter which is 240 cm long, and 3 mm wide
Within the balloon, there is a 16 cm IP segment with 17
ring electrodes spaced 5 mm apart and also a solid state
pressure transducer.
When inflated, the balloon may be distended to a
maximal diameter of 2.5 cm and a CSA of 490 mm2.
The balloon can be filled with a specially formulated
FLIP panometry is a novel method to evaluate esophageal
saline solution – maximum volume 70 cc motility at the time of endoscopy.
It provides comprehensive evaluation of esophageal
function that incorporates esophagogastric junction (EGJ)
distensibility and distension-induced contractility,
PRINCIPLE
IP is a technique designed to measure the relationship of cross-sectional area (CSA) and
pressure during constant volume distention in the GI lumen.
Electrical impedance is converted into an area measurement
The CSA is used to estimate wall tension and strain inside the lumen.
By applying the law of Laplace, the wall tension can be calculated from CSA and pressure
data.
ANALYSIS- DISTENSIBILITY
INDEX
Distension volume, intraballoon pressure, and 16 channels of color-coded luminal diameters as
a topographic plot generated via interpolation between channels.
The EGJ distensibility index (DI) was calculated by realtime software as a luminal cross-
sectional area divided by pressure with the DI values displayed on the real-time monitor for all
16 impedance-planimetry channels
An abnormal EGJ DI was determined if the EGJ DI was <2.8 mm2/mm Hg, which was
classified as reduced EGJ opening (REO);
DISTENSION INDUCED
CONTRACTILITY
The pattern of distension-induced contractility was assessed over the entirety of the FLIP
study (20-70 mL fill volumes).
An esophageal contraction (ie, presence of contractility) was defined as occurring when
esophageal body diameter changes >5 mm occurred in >2 adjacent impedance planimetry
channels.
Direction of contraction propagation was assessed as antegrade or retrograde.
A repetitive pattern of contractility was defined as when 3 consecutive contractions of similar
morphology occurred.
The conceptual advantage of the FLIP device
over HRM lies in the distinction between
sphincter relaxation and sphincter opening.
HRM measures relaxation; the FLIP
quantifies opening.
HRM findings can be equivocal or negative
despite strong clinical suspicion to the
contrary
Impendance panometry can be useful in these
scenarios
ACHALASIA CARDIA
INTRODUCTION
Achalasia cardia (AC) is a primary motor disorder of the esophagus characterized by insufficient lower
esophageal sphincter (LES) relaxation and loss of esophageal peristalsis
Achalasia is a Greek word that means “failure of relaxation”.
Achalasia can be primary (idiopathic) or secondary.
Pathophysiologically, achalasia is caused by loss of inhibitory ganglion cells in the myenteric plexus
The primary distinction from other motility disorders (e.g., Jackhammer oesophagus and distal oesophageal
spasm) is the failure of lower oesophageal sphincter (LES) relaxation in achalasia. Therefore, most of the therapies
are directed towards reduction in LES pressures.
EPIDEMIOLOGY
Achalasia is equally common in both sexes.
Most commonly diagnosed between 40 and 60 years of age, achalasia can present in any age
group
Asian data from Korea showed incidence and prevalence of 0.4 per 100,000 population per year and 6.3
per 100,000 population, respectively, in 2014.6 According to these studies, the incidence of achalasia is
increasing
CLINICAL FEATURES
Dysphagia to both solids and liquids from the onset (occurs in 85–91% of patients) is the most
common presenting feature of achalasia, as liquids require better neuromuscular co-ordination than
solids for oesophageal emptying.
Postures like raising the arms in an erect position increase the intraoesophagael pressure and propel
food in the aperistaltic oesophagus, as the oesophagus is compressed between the spine and the
manubrium sterni.
Regurgitation of undigested food (occurs in 75–91% of patients) is the second most common
presenting symptom. Retrosternal chest pain and heartburn can be seen in 40–60% of patients,
Heartburn and chest pain
Weight loss
Few patients may have emaciation and oral ulcerations caused by regurgitation.
aspiration pneumonia
ECKHARDT SCORING SYSTEM
MEDICAL MANAGEMENT
Oral pharmacological therapy is least popular treatment for AC because of its low efficacy. Drugs have a transient effect on LES
and induce suboptimal change in LES pressure.
Current oral drugs used to treat AC include nitrates, calcium channel blockers, phosphodiesterase inhibitors, and some others
(butylscopolamine, nifedipine, verapamil, carbutoerol, terbutaline, aminophylline, nitroglycerin, vasoactive intestinal peptide,
cimetropium, loperamide, isosorbide, and sildenafil).
These drugs transiently relax LES smooth muscle and facilitate esophageal emptying.
The most commonly employed calcium channel blocker is nifedipine. Its effect is highest 20–45 min after ingestion and lasts
from 30 to 120 min. For best response, nifedepine (10–30 mg) should be ingested sublingually 30–45 min before meals.
Compared with calcium channel blockers, sublingual isosorbide dinitrate not only reduces LES pressure effectively (30–65%)
but also improves symptoms by 53–87%. Duration of effect for nitrate is shorter (30–90 min), and peak effect usually occurs 3–
27 min after ingestion. So isosorbide dinitrate (5 mg) should be administered sublingually 10–15 min before meals.
BOTULINUM TOXIN
Botulinum toxin inhibits the exocytosis of excitatory acetylcholine from the presynaptic neurons, restores the balance between
excitatory and inhibitory influences, and allows muscular relaxation and subsequent decrease in LES pressure
Injection of BT may also be important in patients with a history of failed PD or myotomy, or it may be used as a “bridge” treatment
for symptomatic relief before a more invasive procedure.
Use of BT in AC treatment was first described by Pasricha et al. in 1994 via a prospective trial of 10 symptomatic adult achalasia
patients. An 80 U of BT was injected through a sclerotherapy needle into the LES (1 mL of a 20 U/mL solution into each of the
four quadrants).
Post injection side-effects were infrequent, including transient chest pain, heartburn, and epigastric pain. No ulceration, perforation,
pneumothorax, or abscess were reported. Deaths is reported from acute mediastinitis following BT injection into body.
Repeated BT injections may lead to subsequent submucosal fibrosis making future therapy (pneumatic dilatation or myotomy)
difficult
Older patients and those with vigorous achalasia (type III achalasia in the Chicago classification) were most likely to respond to
endoscopic BT injection
PNEUMATIC DILATATION
POEM
TIMED BARIUM ESOPHAGOGRAM
Timed barium esophagogram is an objective method of quantifying esophageal emptying. Esophageal emptying is
dependent on its contractility and residual LES pressure on swallowing.
The patient ingests 100–250 mL of a 45% barium sulfate suspension in 15–20 s, in order to allow for adequate filling of
the esophagus.
Radiographs in the standing position are taken at 1, 2, and 5 min after the solution is ingested.
Height and width of the barium column can then be used to measure esophageal emptying as a function of time.
TBE may also be a valuable predictor for the need of retreatment after PD
The overall results from this study indicate that esophageal stasis, rather than LES pressure, is the most important
indicator of long-term treatment success in patients with achalasia.-Uday Ghoshal et al
TBE and high-resolution manometry are equally useful in measuring treatment response – society consensus guidelines
DECOMPENSATED ACHALASIA – SIGMOID ESOPHAGUS
Sigmoid esophagus is the end-stage in the progression of AC and accounts for 5% of cases.
Progression of disease in absence of any treatment leads to massive dilatation of the esophagus with axis
deviation and tortuosity resulting in a sigmoid or “tortuous” or “end-stage” esophagus.
Even after treatment, 10% of cases progresses to end-stage achalasia requiring esophagectomy.
Sigmoid esophagus is tortuous (diameter > 6 cm) with axis deviation
CT)—(i) Sigmoid type 1 (S1): the esophagus is significantly dilated and tortuous with single lumen only,
(ii) Sigmoid type 2 (S2): the esophagus is very dilated and tortuous with double lumen on single CT slice
End-stage achalasia can lead to recurrent aspiration, esophageal stasis leading to ulceration, bleeding,
fistulization, or perfortion of the esophageal body, and development of cancer in some cases.
PHENOTYPE BASED THERAPY – KAHRILAS ET AL
THANK YOU
