Updates in esophageal motility testing - chicagosgna.org · Updates in esophageal motility testing Diagnosis and Management of GERD, Motility and GI Functional Disorders November

Updates in esophageal motility testingDiagnosis and Management of GERD, Motility and GI Functional DisordersNovember 18, 2017

Dustin Carlson, MD, MSCIAssistant Professor of Medicine - GastroenterologyNorthwestern UniversityNorthwestern Medicine

Esophageal manometry

Time

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Time

Conventional manometryLine tracings

High-resolution manometryEsophageal pressure topography

Swallow Swallow

High-resolution manometry: esophageal pressure topography

UES

EGJ

Integrated relaxation pressure (IRP)

• Deglutitive LES relaxation• Mean of the 4 seconds (contiguous or non-contiguous) of maximal deglutitive

relaxation in the 10s following UES relaxation; referenced to gastric pressure

HRM/EPT metricsLe

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10 seconds Gastric

EGJ

IRP 9 mmHg

Distal latency

LES

UES

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• Deglutitive inhibition of esophageal contraction• Time from swallow onset (UES relaxation) to contractile deceleration point (CDP)

HRM/EPT metrics

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Distal latency 7 seconds

Contractile deceleration point

LES

UES

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• Inflection point along the 30mmHg isobaric contour (or pressure greater than intrabolus pressure if compartmentalized pressurization) at which propagation slows

• Within 3-cm of EGJ

30

EGJ

Contractile velocity

LES

UES

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• Rate of contractile propagation• Assessment of simultaneous contractions• Essentially replaced by distal latency

HRM/EPT metrics

Spasm: premature vs rapid contractions

Pandolfino et al, Gastroenterology. 2011 141: 469-475

Distal contractile integral (DCI)

LES

UES

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• Contractile vigor• Pressure amplitude x duration x length of distal esophageal contraction, i.e.

transition zone to proximal margin of EGJ

HRM/EPT metrics

20

HRM/EPT interpretation caveats

• Affect manometric pressure:− Patient position−Bolus size−Bolus consistency−HRM assembly

• Normal/abnormal values to follow represent Sierra-vintage assemblies (Medtronic)

• Herregods, TV, et al. Normative values in esophageal high-resolution manometry. Neurogastroenterology and Motility. 2015; 27(2): 175-87

• Mechanical obstruction•History of previous foregut surgery•Reflux esophagitis

HRM/EPT interpretation

• Chicago classification of esophageal motility disorders− Evaluation for primary motor disorders

• Patients evaluated for dysphagia or esophageal chest pain• Patients without previous foregut surgery or mechanical

obstruction

−Based on supine, 5-ml, liquid swallows

Kahrilas, et al. Neurogastroenterology and Motility. 2015; 27(2)Pandolfino et al, Amer J Gastroenterology. 2008 103(1): 627-35

HRM study protocol

• Baseline recording/basal EGJ pressure• 10 supine, 5-ml liquid swallows− Basis for Chicago Classification of esophageal motility diagnoses

Supplementary maneuvers• Upright swallows• Multiple rapid swallows (2ml liquid x 5 q2-3 seconds)• Viscous swallows• Solid swallows• 200 ml free drink• Test meal +/- post-prandial monitoring

Baseline recording• Absence of swallows• Quiet breathing• 30-120 seconds

• Deep breaths

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150mmHg

20

•Accentuates pressure-inversion point•Confirm trans-hiatal catheter positioning

Basal EGJ pressure

30s

Kahrilas, et al. Neurogastroenterology and Motility. 2015; 27(2)

Stepwise HRM interpretationChicago Classification v3.0

Interpretation of esophageal manometryChicago Classification v3.0

Yes Yes

No

AchalasiaType I: Absent contractilityType II: Pan-esophageal pressurizationType III: Spastic• ≥ 20% premature swallows (low DL)

EGJ outflow obstruction• May represent evolving achalasia or mechanical obstruction

No

Yes

No

Ineffective esophageal motility (IEM)• ≥50% ineffective swallows

Normal motility

Yes

No

Abnormal IRP? 100% failed or ≥ 20% premature?

≥50% ineffective swallows

≥ 20% premature, ≥ 20% hypercontractile,

or 100% failed?

Distal esophageal spasm (DES)• ≥ 20% premature swallows (low DL)

Jackhammer esophagus• ≥ 20% swallows with hypercontractile swallows (high DCI)

Absent contractility• 100% failed swallows• Consider achalasia

EGJ outflow obstruction?

Major disorders of peristalsis?

Entities not seen in normal subjects

Minor disorders of peristalsis?

Kahrilas, et al. Neurogastroenterology and Motility. 2015; 27(2)Pandolfino et al, Amer J Gastroenterology. 2008 103(1): 627-35

HRM/EPT metricsSummary

HRM metric HRM abnormal threshold

Associated disorder

Integrated relaxation pressure (IRP)

>15 mmHg(median)

AchalasiaEGJ outflow obstruction

Distal latency < 4.5 seconds Spasm

Distal contractile integral (DCI)

>8000 mmHg-cm-s

<450 mmHg-s-cm

HypercontractileHypocontractile

Interpretation of esophageal manometryChicago Classification v3.0

Yes Yes

No



No

Yes

No

Ineffective esophageal motility (IEM)• ≥50% ineffective (i.e. weak or failed) swallows

Fragmented peristalsis• ≥50% fragmented swallows

Normal motility

Yes

No


≥50% weak, failed, or fragmented swallows


or 100% failed?


Jackhammer esophagus• ≥ 20% hypercontractile swallows (high DCI)







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•Absent peristalsis

•No pressurization

Abnormal LES relaxationMedian IRP > 15 mmHg

0

5

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25

30

35

Achalasia• Abnormal LES relaxation pressure− IRP > upper limit of normal (15 mmHg)

• Absent (type I and II) or spastic (type III) contractility

Time

•Absent peristalsis•Pan-esophageal pressurization

•Spastic

contraction

Time Time

Type 3Type 2Type 1



•<4.5s

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mmHg30

Achalasia subtypes

EarlyType II or III

EGJOO

LateType I

ChronicType II I

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Achalasia - subtype implications

•Absent peristalsis•Pan-esophageal pressurization •Spastic

contraction

Type 3Type 2Type 1



•<4.5s

•Most common•Best response to therapy

•Least common•Worst response to therapy

Achalasia subtypes - prognosis

Publication N, (Rx type) Type I Type II Type IIIPandolfino 2008 [1] 99

(PD, LHM, Botox)56%

(n=21)96%

(n=49)29%

(n=29)

Salvador 2010 [2] 246(LHM)

85%(n=96)

95%(n=127)

69%(n=23)

Pratap 2011 [3] 51(PD)

63%(n=24)

90%(n=24)

33%(n=3)

Rohof 2013 [4] 176(RCT: PD, LHM)

86% (PD)81% (LHM)

(n=44)

100% (PD)95% (LHM)

(n=114)

40% (PD)86% (LHM)

(n=18)

Percent with ‘good’ outcome

[1] Pandolfino JE, et al Gastroenterology 2008;135:1526[2] Salvador R, et al J Gastrointest Surg 2010;14:1635

[3] Pratap N, et al Neurogastroenterol Mot 2011;17:205[4] Rohof W, et al Gastroenterology; 2013; 144(4)

Slide courtesy of Dr. Peter Kahrilas

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Achalasia – subtype implications

•Absent peristalsis•Pan-esophageal pressurization •Spastic

contraction

Type 3Type 2Type 1



•<4.5s

•Most common•Best response to therapy

•Least common•Worst response to therapy

•Myotomy preferred treatment

Achalasia treatment

• Pharmacologic (off-label uses)− Calcium channel antagonists− Nitrates− Anti-cholinergic− Phosphodiesterase 5 inhibitors

• Botulinum toxin injection-----

•Pneumatic dilation•Heller’s myotomy−With partial fundoplasty

•Per-oral endoscopic myotomy (POEM)

Achalasia treatment

• Botulinum toxin injection− Endoscopic− Pre-synaptic inhibition of acetylcholine release− ~50% reduction in LES pressure− 6-24 month duration of effect − Typically reserved for non-surgical (or pneumatic dilation)

candidates

Vaezi, M, et al. ACG clinical guidelines. Amer J of Gastroenterol. 2013; 108.

Achalasia treatment

Pneumatic dilation− Endoscopic− Typically fluoroscopy-guided− Staged dilations 30mm, 35mm, +/- 40mm

• Complication:− Perforation rate ~2% (1-4%)

Microvasive® Dilator (3.0, 3.5, or 4.0 cm)Passed over guidewire, imaged with fluoroscopy

Achalasia treatment

Laparoscopic Heller’s Myotomy− With Dor Fundoplication (anterior, 1800) or − Toupet fundoplasty (posterior, 2700)

Peters & DeMeesterMinimally Invasive Surgery of the Foregut 1994

Achalasia treatment: European Achalasia Trial

Years since start of studyMoonen, et al. Gut. 2016

Boeckxstaens GE, et al. NEJM 2011:364:1807-1816

Pneumatic dilation*Laparoscopic Heller’s myotomy

RCT: Pneumatic dilation vs Laparoscopic Heller’s myotomy

*+/- repeat dilation

Achalasia treatmentPer-oral endoscopic myotomy (POEM)1) Enter into the submucosa in the mid esophagus2) Creation of submucosal tunnel ≈ half esophageal circumference3) Myotomy begun ≈ 3 cm distal to entry, ≈ 7 cm above EGJ4) Myotomy completion5) Clipping

Phalanusitthepha, C. et al. Annals of Translational Medicine. 2014; 2(3)

1 2 3 4 5

POEM outcomes

•115 consecutive patients (2012-2015)−After 15 patient “learning curve”

•Follow-up at > 1 year−Average 2.4 years, range 12 - 52 months

•Positive outcome in 92% of patients− Eckardt score of ≤3− Positive outcome in 18/20 (90%) of type III achalasia

•GERD 40% (of 68 patients evaluated)− Positive pH study or LA-B-D esophagitis

Northwestern experience

Hungness, E. et al. Annals of Surgery, 2016; 264(3): 508-17

Achalasia treatment: POEMA trial

• Abstract: DDW 2017• International, multi-centered randomized trial of patients

with newly diagnosed achalasia• 133 patients: 66 PD and 67 POEM• 12 month follow-up

− Treatment success (Eckardt score of ≤3) rates:

•PD: 52/66 (79%)•POEM: 59/64 (92%)

RCT: Pneumatic dilation vs POEM

Secondary achalasia• Malignant pseudoachalasia− Gastric adenocarcinoma; metastatic lung, liver, pancreas− Paraneoplastic – rare− Clinical risk factors:

•older age (>60 yrs)•short symptom duration (< 1 year)•weight loss•EGJ appearance

•Evaluation:−Endoscopic ultrasound−CT

Ponds, FA. et al. Aliment Pharmacol Ther. 2017; 45(11)

Yes Yes

No



No

Yes

No



Normal motility

Yes

No




or 100% failed?








Esophageal motility disordersChicago Classification v3.0


EGJ outflow obstruction

• May represent:− Achalasia variant

• Early/“Evolving” achalasia− Subtle mechanical

obstruction− Hiatal hernia− Pressure artifact

• Vascular or anatomic

− Normal motility• 15-mmHg IRP = 95th percentile of

asymptomatic controls

IRP 30 mmHg

Distal latency 8s

DCI 900 mmHg-s-cm

100500 150

mmHg30


• “Real” EGJOO?• HRM:− Degree of IRP elevation

• 15-mmHg IRP = 95th percentile of asymptomatic controls


• “Real” EGJOO?• HRM:− Degree of IRP elevation− Contractile/peristaltic pattern

7s

IRP 28 mmHg IRP 18 mmHg

DCI 9000mmHg-cm-s

5s

100500 150

mmHg30

IRP 32 mmHg

DCI 215mmHg-cm-s

6s


• “Real” EGJOO?• HRM:− Degree of IRP elevation− Contractile/peristaltic pattern− Elevated intra-bolus pressure

• Compartmentalized pressurizationIRP 32 mmHg

100500 150

mmHg30

IRP 35 mmHg

7s

DCI 4000mmHg-s-cm

IRP 30 mmHg

8s

DCI 900 mmHg-s-cm


• “Real” EGJOO?• HRM:− Degree of IRP elevation− Contractile/peristaltic pattern− Elevated intra-bolus pressure − Upright swallows

• Normalization of IRP• < 12 mmHg

IRP 23 mmHg

100500 150

mmHg30

IRP 5 mmHg

UPRIGHT

SUPINE


• “Real” EGJOO?• HRM:− Degree of IRP elevation− Contractile/peristaltic pattern− Elevated intra-bolus pressure − Upright swallows

• Normalization of IRP

• Supplementary testing− Esophagram

•Timed barium esophagram•Barium tablet

− EndoFLIP®− Endoscopic ultrasound

100500 150

mmHg30

Yes Yes

No



No

Yes

No



Normal motility

Yes

No




or 100% failed?








Esophageal motility disorders


Chicago Classification v3.0

Distal esophageal spasm

• Rare• Premature contractions• Simultaneous contractions• Normal LES relaxation• Achalasia variant?

IRP < 15 mmHg

Distal latency < 4.5s

Yes Yes

No



No

Yes

No



Normal motility

Yes

No




or 100% failed?











Hypercontractile esophagus

• Jackhammer esophagus− DCI > 8,000 mmHg-cm-s

• +/- Normal LES relaxation• Secondary manifestation?• Achalasia variant?

IRP < 15 mmHg

Distal contractile integral > 8000 mmHg-cm-s

Management of spastic esophageal motility disorders

• Type III achalasia• Distal esophageal spasm• Hypercontractile esophagus

• LES +/- extended myotomy− POEM

• Botulinum toxin injection• Pharmacologic agents (**off label use)− Smooth muscle relaxants

• CCB• Nitrates• Anti-cholinergics• PDE5-inhibitors

− Secondary manifestation?• Treat underlying cause

− Trazodone− TCAs - amitriptyline

Yes Yes

No



No

Yes

No



Normal motility

Yes

No




or 100% failed?











Absent contractility

• Failed swallows/absent peristalsis• Normal LES relaxation• Association with connective

tissue disease (not diagnostic of CTD)

• Consider achalasia• Borderline IRP

• Management− Dietary modifications− Reflux therapies

IRP < 15 mmHg

Yes Yes

No



No

Yes

No



Normal motility

Yes

No




or 100% failed?








Chicago Classification v3.0Esophageal motility disorders


Functional dysphagia

• Not meeting criteria for a major motility disorder• Consider evaluation for subtle mechanical obstruction− e.g. esophagram with barium tablet

• Management− Dietary modifications− Reflux therapies− Empiric dilation− Neuromodulator/cognitive behavioral therapy/hypnosis− Observation and re-evaluation for progression

HRM beyond the Chicago Classification

• 10 supine, 5-ml liquid swallows− Basis for Chicago Classification of esophageal motility diagnoses

• Supplementary maneuvers− Upright, 5-ml liquid swallows− Multiple rapid swallows (2ml liquid x 5 q2-3 seconds)− Viscous swallows− Solid swallows− 200 ml free drink− Test meal +/- post-prandial monitoring

• High-resolution impedance manometry (HRIM)

High-resolution IMPEDANCE manometry

• Bolus clearance/transit− Complete/incomplete

• Automated impedance analysis− Pressure-flow metrics

• Bolus flow time− Measures esophageal emptying

• Esophageal impedance integral ratio− Measure bolus retention

• Impedance bolus height− 200 ml drink− Measures esophageal retention

• Akin to TBE 100500 150

mmHg

Bolus presentBolus absent

30

Post-prandial studies

• For regurgitation and belching +/- PPI-unresponsive reflux symptoms• Protocol:− High-resolution impedance manometry− Swallow protocol (to exclude achalasia)− Refluxogenic meal (patient choice)− Monitor for 60-90 minutes after meal

• Annotated symptomatic events•Interpretation:−Transient LES relaxations: GERD−Rumination−Supra-gastric belching

1. Increase in gastric pressure

− > 30 mmHg2. Followed by retrograde

flow of gastric contents3. Increase in intra-

esophageal pressure4. Relaxation of UES

Rumination

100500 150

mmHg30

3s

Supragastric belching

3s

1. Negative intra-thoracic pressure2. UES relaxation3. Antegrade air flow (impedance increase)4. Retrograde air flow5. May be repetitive

Post-prandial HRIM

• 94 patients with PPI-non-responsive symptoms

−20% rumination (+/- TLESRs)

−42% supragastric belching (+/- TLESRs)

−14% GERD (TLESRs only)−24% “normal”

• Implications:−Management of rumination and supragastric belches

with behavioral therapies−Direct TLESR inhibitors use?

Yadlapati, R. et al. Clin Gastroentol Hepatol. 2017; epub Sept 12.

Thank You

Questions?• [email protected]

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Updates in esophageal motility testing - chicagosgna.org · Updates in esophageal motility testing Diagnosis and Management of GERD, Motility and GI Functional Disorders November