CONCETTI GENERALI SULLE DISFAGIE DI ORIGINE ESOFAGEA

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1 MECCANISMI FISIOLOGICI AUTOMATICO-RIFLESSI DELL ESOFAGO CONCETTI GENERALI SULLE DISFAGIE DI ORIGINE ESOFAGEA Michele Di Stefano Clinica Medica 1 Fondazione IRCCS Policlinico S.Matteo Università di Pavia Pavia PHARYNGOESOPHAGEAL REFLEXES Deglutition Balloon Distention Andreollo NA et al, Gut

2 UES TONE IN PTS WITH ESOPHAGOPHARYNGEAL REGURGITATION SALINE PERFUSION ACID PERFUSION 18 controls patients controls patients sham saline sham saline 18 sham acid sham acid UES TONE (mmhg) Gerhardt DC et al, Gastroenterology 198 ESOPHAGEAL MOTOR ACTIVITY AND INHIBITORY REFLEXES Pharyngoesophageal Inhibitory Reflex Deglutitive Inhibition UES SW SW perfusion Proximal body Distal body Pharynx 5 cm Below UES LES LES stomach 1 cm Below UES Swallows Hollis JB et al, J Appl Physiol 1975 Trifan A et al, Gastroenterology

3 MULTIPLE REPETITIVE SWALLOWS IN EARLY PD Esophageal manometry MRS test Transit pattern and no. of swallows 1 2 >3 +ve -ve +ve -ve Prevalence (%) 6 4 Prevalence (%) 6 4 Prevalence (%) Complete Incomplete Sung HI et al, Mov Disorders 21 MANOMETRIC ABNORMALITIES AND SWALLOWING IN PD UES AND PHARYNX Incomplete relaxation Low pharyngeal contraction amplitude Synchronous contractions ESOPHAGEAL BODY Aperistalsis Ineffective peristalsis Nonpropagated contractions Simultaneous contractions Proximal esophageal spasm LES High resting pressure Incomplete relaxation 3

4 THREE QUESTIONS ARISE FROM STUDIES Are the abnormal findings more frequent than in age-matched controls? Do they correlate with the severity of disease? Do they relate to dysphagia? RADIOLOGIC ABNORMALITIES AND SWALLOWING IN PD Oral Pharyngeal Esophageal Ali et al 1996 Bushmann et al 1989 Birne et al 1994 Calne et al 197 Edwards et al 1994 Kurihara et al 1993 Robbins et al, 1986 Stroudley et al

5 MECHANISMS OF ORO-PHARYNGEAL DYSPHAGIA IN PD Ali GN, et al. Gastroenterology 1996 MANOMETRIC ABNORMALITIES OF THE ESOPHAGUS IN PD Motility alterations and dysability score Motility alterations and severity of dysphagia Aperistalsis or DES and dysphagia 3 3 < daily > daily -ve +ve Prevalence (%) NS NS P<.5 Castell JA, et al. NGM 21 5

6 DYSPHAGIA AND MYASTHENIA GRAVIS Normal Subject Myasthenia Gravis Ertekin C et al, JNNP 1998 TREATMENT OF MYASTHENIA GRAVIS AND DYSPHAGIA During anticholinesterase therapy 18 hours after Withdrawal of Therapy Ertekin C et al, JNNP

7 PREVALENCE OF DYSPHAGIA IN ACUTE STROKE Swallowing screening test Prevalence (%) Diagnostic test Prevalence (%) Gordon et al Kidd et al Wade et al Smithhard et al Kidd et al Hamdy et al Odderson et al Hamdy et al Hinds et al Sala et al Lim et al Daniels et al Mann et al Kim et al 2 44 Lim et al Sharma et al Parker et al Schelp et al MORTALITY IN STROKE WITH AND WITHOUT DYSPHAGIA Cumulative Survival (%) Non Disphagic pts Disphagic pts Time (months) Hamdy et al, 24 7

8 PNEUMONIA IN NEUROLOGICAL DISORDERS PREVALENCE IN STROKE PATIENTS Prevalence (%) CAUSE OF DEATH IN PARKINSON S DISEASE Prevalence (%) Gordon et al 1987 DePippo et al 1994 Kidd et al 1995 Gottlieb et al 1996 Chua et al 1996 Smithard et al 1996 Sala et al 1998 Mann et al 1999 Lim et al Beyer et al 21 Fall et al 23 D Amelio et al 26 Pennington et al MORTALITY AND NUTRITIONAL STATUS MALNOURISHED WELL NOURISHED Discharged In Hospital Discharged In Hospital 45% 26% 53% 38% 29% 9% Mortality Mortality Larsson et al, Clin Nutr 199 8

9 PREVALENCE OF ESOPHAGEAL MOTILITY ALTERATIONS DURING THE EARLY PHASE FOLLOWING STROKE Esophageal Manometry results two days after hospitalization Without dysphagia With dysphagia % of complete peristaltic sequences P<.1 Micklefield et al, Dtsch Med Wochenschr 1999 PREVALENCE OF ESOPHAGEAL MOTILITY ALTERATIONS IN STROKE - EARLY vs LATE PHASE - Esophageal Manometry results within 5 days vs 3 weeks Complete peristaltic sequences Propagation of peristaltic sequences Barthel Index Early Late Early Late Early Late % 6 4 Cm/sec 3 2 Score P<.5 P<.3 P<.3 Aithal et al, DDS

10 SOLID-STATE HIGH-RESOLUTION UES MANOMETRY UES HIGH RESOLUTION MANOMETRY IN GLOBUS Peng et al, JCG 214 1

11 UES HIGH RESOLUTION MANOMETRY IN GLOBUS Peng et al, JCG 214 UES HIGH RESOLUTION MANOMETRY AND VIDEOFLUOROSCOPY IN BRAINSTEM STROKE PATIENTS WITH DYSPHAGIA Normal swallow Stroke patient Lan et al, JCG

12 CONCLUSIONS Neurological disorders may cause alterations of esophageal peristalsis and, in turn, esophageal dysphagia In patients with neurological disorders and dysphagia, esophageal manometry should be performed HRM and impedance-hrm may improve the accuracy of the diagnostic algorithm of patients with dysphagia GRAZIE PER L ATTENZIONE 12