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8/22/2019 Gastroenterology and Hepatology - Upper GI Motility Disorders
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Upper GI Motility Disorders
Ron Schey, MD
Clinical Assistant Professor
Division of Gastroenterology & HepatologyUniversity of Iowa Hospitals and Clinics
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Dysphagia
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50 y.o male
3 months of dysphagia solids and liquids
Weight loss 10 lb
PMH: Asthma INH-Beta 2 agonists/steroids
Hypertension ACE Inhibitors
NIDDM- Diet controlled
GERD H2 Blockers (sos)PSH: None
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Main esophageal symptomsHeartburn- Characteristic Symptom of GERD
Regurgitation- Another characteristic GERDsymptom
Dysphagia - Difficulty in swallowing
Odynophagia - Pain on swallowing
Nonspecific esophageal symptomsGlobus Hiccups
Chest Pain Nausea/vomiting
Rumination Belching
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Esophageal Anatomy
UES
LES
Striated
Muscle
Smooth
Muscle
20 -22 cm long muscular tube
Inner circular layerOuter longitudinal layer
Sphincters at each end
Myenteric plexus between layers
Flat network of nerve cells
and axons
TransitionZone
Upper 5% striated muscle
Middle 35-40% mixed Lower 50-65% smooth muscle
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UES
LE
S
Esophageal Function
Tubular Esophagus
Peristaltic ring contractions
Longitudinal shortening
Lower Esophageal Sphincter
Tone at rest (myogenic)
Relaxes with swallows
Upper Esophageal Sphincter
Maintains tone at rest (neurogenic)Opens with swallows
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Control of Esophageal
Motor Function
Striated Muscle - CNS Control Nucleus ambiguous
Motor end-plates
UES tone- tonic neural activity
Peristalsis-sequential motor
neuron activation
Smooth muscle control - ENSDorsal motor nucleus -
myenteric neurons -
muscle
Timing of peristalsis -NO
Strength of peristalsisAch/SP
LES tone myogenic + Ach/NO
Relaxation NO
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Mechanical obstruction
Neoplasms (Intrinsic and Extrinsic)
Peptic stricturesForeign body
Paraesophageal hernia
Esophagitis (Peptic/Infectious)
Neuropathy - Achalasia, HIV
Myopathy
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Neuromuscular diseases
CNS( stroke, MS, ALS, Parkinsons, Tumor)
PNS (Polio, MG, Neuropathy, DM)
Myopathy (MD, Polio)
Structural AbnormalitiesNeoplasm (Squamous Cell CA, Lymphoma)
Infection (Candida, CMV)
Cricopharyngeal Bar/Zenkers Diverticulum
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Myopathic DiseasesSmooth Muscle Esophagus
Collagen Vascular Diseases (CREST,
Scleroderma, SLE)
Muscular Dystrophies Familial Visceral Myopathies
PathologyMuscle degeneration and replacement by fibrous connective tissue
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Heartburn-RefluxEsophagitis Esophageal strictureMotor abnormality
Odynophagia - Severe Inflammation (ulcer)Infection (CMV, Herpes, Candida)Peptic esophageal ulcer
Pill esophagitis
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Identification of esophagitis
Identify infections in immunocompromised patients
Exclude pseudo-achalasia before treatment
Treatment of esophageal diseases (peptic stricture, tumor,achalasia)
Identifyeosinophilic esophagitis
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Peptic Esophagitis
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Peptic Stricture
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Schatzki Ring
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Candida Esophagitis
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Paraesophageal Hernia
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Nissen Fundoplication
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Eosinophilic Esophagitis-Histopathlogy
Number of Epithelial Eosinophils/HPF, n (Range)
Proximal Esophagus 78.7 (2-158) 25.6 (0.2-69.6)Distal Esophagus 117.5 (29-402) 37.6 (3.8-109)
Eosinophils Superficial and form Microabcesses
Insignificant Number in Antrum and Duodenum
Basal Cell Hyperplasia, % (Range) 65.1 (20-80)
Papillary Hyperplasia, % (Range) 79.7 (50-90)
Remedios, et al. Gastro. Endoscop. 63: 3-12, 2006Straumann, et al. Gastro. 125:1660, 2003.
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FoodImpaction
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Adenocarcinoma of the Esophagus
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Barium esophagram/Videoesophagography
Upper endoscopy
Esophageal manometry
Water perfused catheter
Solid state catheter Dent sleeve
Impedance Manometry
High Resolution, Multichannel
Esophageal pH monitoring Catheter (+/- impedance)
Wireless Bravo (endoscopic placement)
Esophageal transit and GE reflux scintigraphy
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Obstructive Lesion vs Motor Abnormality
Upper Esophageal Webs or Strictures
Cricopharyngeal BarZenkers (Pharyngoesophageal) Diverticulum
Schatzkis Ring
Intramural LesionsCompression by Extraesophageal Lesions
Compliment to Manometry - Bolus Transport
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Diffuse Esophageal
Spasm
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Diffuse Esophageal Spasm
Striated muscle - normal
Wet swallows - produce simultaneous
pressure waves in smooth muscle esophagus with
Periods of normal peristalsis
Occasional spontaneous pressure waves
Repetitive contractions (>2 peaks)Prolonged duration pressure waves (>6 sec)
High amplitude pressure waves
A h l i
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Achalasia
Barium Swallow
Birds beak at LES
Failed LES relaxation
Dilated esophagus
Sigmoid esophagus
Failed 1o peristalsis
A h l i d
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Achalasia - Endoscopy
Rule out pseudo-achalasia
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1A conventional
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22
25
28
32
36
40
44
513 sec
Distan
cefromNares
(cm)
Pharynx
UES
LES
Gastric
19
100
100
Pressure(m
mHg)
100
100
100
100
100
50
100
WS
manometry tracing
M t / Vid fl
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Manometry / Videofluoroscopy
UES
cm
aboveLES
o
o
o
o
o
o
o
3.0 s
3.9 s
6.5 s
8.0 s
9.3 s
11.8 s
13.1 s
3.9
6.5
8.0
9.3
11.8
LES Open
3.0
0 10 20
11
9
7
5
3
1
LES0
160
Seconds
J. Ren, Am. J. Physiol. 261: G417, 1991
1B Transformation to 3D space
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180
160
140
120100
80
60
40
20
Pressure
(mmHg)
p
1E. Transformation to color contour
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180
160
140
120
100
80
60
40
20
1F. Transformation to 2D representation of color contour
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3 sec
UES
LES
19
24
29
39
34
44
49
54
Cm
fromNares
0
20
40
60
80
100
120
140
mmHg
*
**
Striated Muscle
Transition Zone
Smooth
Muscle
p
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SolidsMechanical Obstruction
Sudden
Foreign
Body
Intermittent
Schatzkis
Ring
Progressive
Heartburn
GERD
Stricture
>50 yo
Carcinoma
Eosinophilic
Esophagitis
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Solids or LiquidsInfection/Neuromuscular
Recent
Immunosuppression
Antibiotics
HIV Infection
Candida
CMV
Intermittent
Chest Pain?
Motility
Disorder
Progressive
Achalasia Scleroderma
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Common clinical problem
Between 70-80% patients Significant overlapbetween oropharyngeal and esophageal disorders-History & Tests often useful
Motility disorders are quite common- HRM,Impedance may provide novel information
Eosionophillic esophagitis should be recognized
Detailed evaluation reveals abnormalities in >60% of
patientsNon-obstructive, functional dysphagia remains a
challenge
Between 70-80% of patients can be helped with lifestyle modifications, drugs, endoscopy & surgery
Recommended