CONCETTI GENERALI SULLE DISFAGIE DI ORIGINE ESOFAGEA
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1 LA DISFAGIA ESOFAGEA Pavia, 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 18 SALINE PERFUSION ACID PERFUSION controls patients controls patients sham saline sham saline 18 sham acid sham acid UES TONE (mmhg) p<.1 NS p<.1 NS 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 PARKINSON S DISEASE 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 IN PARKINSON S DISEASE 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 RADIOLOGIC ABNORMALITIES IN PARKINSON S DISEASE 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 MECHANISMS OF ORO-PHARYNGEAL DYSPHAGIA IN PD Ali GN, et al. Gastroenterology
5 MANOMETRIC ABNORMALITIES OF THE ESOPHAGUS IN PD Prevalence of esophageal peristalsis alterations in 22 patients with PD= 73% Motility alterations and dysability score 3 3 Motility alterations and severity of dysphagia < daily > daily Aperistalsis or DES and dysphagia -ve +ve Prevalence (%) NS NS P<.5 Castell JA, et al. NGM 21 DYSPHAGIA AND MYASTHENIA GRAVIS Normal Subject Myasthenia Gravis Ertekin C et al, JNNP
6 TREATMENT OF MYASTHENIA GRAVIS AND DYSPHAGIA During anticholinesterase therapy 18 hours after Withdrawal of Therapy Ertekin C et al, JNNP 1998 PREVALENCE OF DYSPHAGIA IN ACUTE STROKE Swallowing screening test Prevalence (%) Diagnostic test Prevalence (%) Gordon et al 1987 Wade et al 1987 Kidd et al 1993 Odderson et al 1995 Hinds et al 1998 Lim et al Kidd et al 1993 Smithhard et al 1996 Hamdy et al 1997 Hamdy et al 1998 Sala et al 1998 Daniels et al 1998 Mann et al 1999 Kim et al 2 Lim et al 21 Sharma et al 21 Parker et al 24 Schelp et al
7 MORTALITY IN STROKE WITH AND WITHOUT DYSPHAGIA Cumulative Survival (%) Non Disphagic pts Disphagic pts Time (months) Hamdy et al, 24 PNEUMONIA IN NEUROLOGICAL DISORDERS PREVALENCE IN STROKE PATIENTS Prevalence (%) CAUSE OF DEATH IN PARKINSON S DISEASE Prevalence (%) Gordon et al Beyer et al 21 2 DePippo et al Fall et al Kidd et al D Amelio et al Gottlieb et al Pennington et al Chua et al Smithard et al Sala et al Mann et al Lim et al
8 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 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
9 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 1999 POST-STROKE OROPHARYNGEAL DYSPHAGIA IS ASSOCIATED WITH IMPAIRED CORTICAL ACTIVATION TO PHARYNGEAL SENSORY INPUTS Dysphagia No Dysphagia HV Cabib et al, Eur J Neurol 217 9
10 POST-STROKE OROPHARYNGEAL DYSPHAGIA IS ASSOCIATED WITH IMPAIRED CORTICAL ACTIVATION TO PHARYNGEAL SENSORY INPUTS Capsaicin 15 µmol/l Piperine15 µmol/l Piperine1 mmol/l Menthol 1 mmol/l Menthol 1 mmol/l Corn-starch based thickener Capsaicin 15 µmol/l Piperine15 µmol/l Piperine1 mmol/l Menthol 1 mmol/l Menthol 1 mmol/l Corn-starch based thickener Alvarez-Berdugo D et al, Neurogastroenterology and Motill 217 SOLID-STATE HIGH-RESOLUTION UES MANOMETRY 1
11 UES HIGH RESOLUTION MANOMETRY IN GLOBUS Peng et al, JCG 214 UES HIGH RESOLUTION MANOMETRY IN GLOBUS Peng et al, JCG
12 UES HIGH RESOLUTION MANOMETRY AND VIDEOFLUOROSCOPY IN BRAINSTEM STROKE PATIENTS WITH DYSPHAGIA Normal swallow Stroke patient Lan et al, JCG 214 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 12
13 GRAZIE PER L ATTENZIONE 13
CONCETTI GENERALI SULLE DISFAGIE DI ORIGINE ESOFAGEA
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
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