What can you expect from the lab?

Transcription

1 Role of the GI Motility Lab in the Diagnosis and Treatment of Esophageal Disorders Kenneth R. DeVault MD, FACG, FACP Professor and Chair Department of Medicine Mayo Clinic Florida What can you expect from the lab? Reflux Confirm excessive acid reflux Measure nonacid and weakly acid reflux events Correlate symptoms with reflux events Evaluate completeness of acid suppression Motility Diagnosis or confirm specific disorders Provide some explanation for atypical esophageal symptoms 1

2 Ambulatory ph Monitoring 2 Channel ph recording 2

3 Impedance-pH Monitoring Catheter Allows measurement of acid and nonacid reflux Reasonable choice for monitoring patients on therapy Values and interpretation of nonacid reflux not as well characterized and difficult to interpret 17 cm 15 cm 9 cm 7 cm 5 cm 3 cm Esophageal ph (5 cm above LES) LES Gastric ph (10 cm below LES) Tutuian R, Castell DO. Gastrointest Endoscopy Clin N Am. 2005;15: Reflux Events A-Acid B-Weakly acid C-NonAcid Hila et al CGH 2007;5:

4 Catheter-Free ph Monitoring System Small ph sensor and radiotransmitter placed in the esophagus Data recorder (receiver) worn by patients Capsule detaches from esophagus and is passed through the digestive tract Allows patients to eat and partake in everyday activities Tolerability of Bravo Capsule vs Catheter- Based Monitoring Conventional Bravo capsule (% of patients) nasal system (% of patients) P value Throat discomfort P<0.001 Esophageal discomfort P<0.05 Change in diet P<0.001 Change in activity P<0.001 Inability to undergo monitoring Overall satisfaction score P<0.001 (0=very satisfied; 5=never do again) Pandolfino JE et al. Am J Gastroenterol 2003;98:

5 Extended (48hr) monitoring increases the yield of ph testing hour Bravo 18 ph Studies (30%) abnormal 14 both days (46%) normal 8 both days 6 26 (24%) discordant 4 16 (+) day 1 only 2 10 (+) day 2 only 0 DeVault, Ferguson et al. DDW Detachment Study 5

6 Pros and Cons of Ambulatory ph testing Capsule Based ph Catheter-based ph Pti Patient tmay be more inclined The patient t may not follow to follow daily activity usual daily routine 48-hour testing capabilitymay increase sensitivity Higher sampling rate 24-hour study only Fixed position Allows multisite monitoring Early detachment is possible Catheter can move and slip Endoscopy and capsule- into the stomach therefore cost is higher Normal data set more robust Allows impedance testing without additional expense/discomfort Either system is acceptable for distal esophageal acid recording Temporal Associations (1) Symptom Index (SI) = no. of reflux and cough events x 100% no. of cough events (2) Symptom Severity Index (SSI) = no. of reflux and cough events x 100% no. of reflux events (3) Symptom Association Probability (SAP) SI/SSI: Value 50% represents +ve association SAP: calculates whether cough follows reflux more frequently than would be expected by chance alone, using Fisher s Exact Test SAP = (1-P value) x 100%, where value 95% represents +ve association 6

7 Results of ph Monitoring in Symptomatic Patients on Therapy 30 istal Total Time ph < 4 % Di Upper limit of normal 0 QD Typical GERD (n = 175) BID QD BID Atypical GERD (n = 145) Charbel and Vaezi. AJG 2004 Ambulatory Reflux Monitoring Define the Question! Does the patient have reflux? Monitor off therapy Tubeless or Tube-based testing OK Is the patient s reflux refractory to Rx? Monitor on therapy Gastric and/or impedance monitoring may help Is GERD causing proximal symptoms? Proximal or Impedance monitoring 7

8 Potential Outcomes of ph study (0ff Rx) Acid Exposure Severe (>10%) Severe (>10%) Mild (5-10%) Mild (5-10%) Negative (<5%) Negative (<5%) SI/SAP positive negative positive negative positive negative Variables in ph study (On Rx) Acid Exposure Number of reflux events SI/SAP (acid or nonacid) Increased (>5%) increased Positive Borderline (1.6-5%) normal negative Normal (<1.6%) On therapy testing rarely provides definitive evidence of GERD in patients without a history of -esophagitis (LA B or greater), -long segment BE -previous positive ph test off therapy 8

9 ACG GERD GUIDELINES 2013 Ambulatory esophageal reflux monitoring is indicated d before consideration of endoscopic or surgical therapy in patients with non-erosive disease as part of the evaluation of patients refractory to PPI therapy, and in situations when the diagnosis of GERD is in question. Ambulatory reflux monitoring is the only test that can assess reflux symptom association Motility Testing Define Specific Disorders Practical Approach to the Chicago Classification 9

10 Traditional Manometry Diagnosis Spastic Disorders Achalasia Aperistalsis, intact usually poorly relaxing LES Distal Spasm >20% simultaneous contractions High Pressure (Nutcracker) Distal amplitude > 180 mm Hg Traditional Manometry Diagnosis Weak Disorders Scleroderma Aperistalsis, weak to absent LES, associated rheumatologic findings (usually) Aperistalsis Aperistalsis that does not fit into achalasia or scleroderma (reflux related) Ineffective Esophageal Motility Usually reflux related 10

11 Normal Swallow in HRM Pandolfino Thorac Surg Clin 2011;21: EGJ/LES Relaxation Pandolfino Thorac Surg Clin 2011;21:

12 Achalasia Subtypes Pandolfino Thorac Surg Clin 2011;21: Other Spastic Disoders Nutcracker (super squeezer) Major: Peristaltic pressure in distal esophagus >180 mm Hg Minor: Repetitive, prolonged (>6 sec) contractions Jackhammer Esophagus DCI >8000 Can be due to increased pressure, prolonged contractions or a combination DES >20 % simultaneous contractions 12

13 HRM examples of high pressure peristalsis Pandolfino Thorac Surg Clin 2011;21: Description of Impaired Peristalsis Nonspecific Esophageal Motility Disorder (NEMD) Disorder of Ineffective Motility (IEM) 50% or more swallows with failed or weak (<30 mm Hg) contractions High Resolution concepts Failed Peristalsis (HRM/Impedance) Weakness or gap in 20 mm Hg peristaltic wave that produces bolus escape (<3cm) Hypotensive peristalsis Longer weak peristaltic segments 13

14 Chicago Classification with normal GEJ relaxation Absent peristalsis 100% of swallows with no peristalsis Weak peristalsis (at least 30% with) Failed peristalsis Diffuse hypotensive breaks Focal hypotensive breaks Rapid segmental contractions between proximal and distal segments with a small break Examples Bulsiewicz et al Am J Gastroenterol 1999;104:

15 There are several mechanisms that may lead to bolus escape Pandolfino Thorac Surg Clin 2011;21: How has HRM (and stationary impedance?) redefined the diagnosis of disorders with impaired peristalsis in the esophagus? NEMD-Very nonspecific IEM-More specific HRM allows us to characterize every swallow and perhaps have a better understanding of the efficiency of each swallow Remaining questions: Is 30% the correct number? Are there enough normal data to determine that %? Do any of these numbers predict outcomes? Particularly in regards to surgical outcomes Why do some patients have symptoms and others do not with the same manometry findings? 15

16 HRM Take Home Points Computer tends to overcall EG Outflow Obstruction Type I and II achalasia are very specific but still take a history of compare to a barium study Be careful with Type III Compare with barium Does not respond as well to treatment Is it a DES variant?? Spasm or DES also needs to be carefully correlated with the rest of the clinical situation HRM has expanded number of weak diagnoses, but all need to be carefully correlated with the clinical situation Impedance may help better understand the significance of motility findings on HRM 16