Manometry Conundrums

Transcription

1 Manometry Conundrums Gastroenterology and Hepatology Symposium February 10, 2018 Reena V. Chokshi, MD Assistant Professor of Medicine Division of Gastroenterology, Hepatology, & Nutrition Department of Internal Medicine

2 Disclosures I do not have relevant financial relationships with commercial interests related to the content of this presentation.

3 Overview Basics of esophageal manometry Conundrums of analysis and interpretation Conundrums of clinical management

4 Esophageal Manometry Measurement of pressure contractions, amplitude and coordination Catheter based testing with patient participation Indications: ***Dysphagia, including confirmation of achalasia Chest pain ph probe placement Preoperative for anti-reflux interventions

5 Procedure Technique Instill nasal anesthetic lubricant Pass catheter through nares into stomach while pt upright Allow patient adjustment to supine Deliver fluid via syringe and ask patient to swallow (usu 10 swallows of 5ml each) Allow time between fluid administration where patient is not allowed to swallow Remove catheter

6 Procedure Variability Bolus characteristics Patient position Number of swallows Provocative maneuvers

7 Normal Peristalsis

8 Clouse RE, et al. Am J Gastroenterol 1998.

9 Bansal A, Kahrilas PJ. Curr Opin Gastroenterol 2010.

10 Pharynx UES region Striated-smooth muscle pressure trough Intra-smooth muscle pressure trough 2cm Esophageal body-les pressure trough LES region 2s Stomach Clouse RE, et al. Am J Physiol Clouse RE, Prakash C. Dig Dis 2000.

11 Analysis Landmarks UES, LES, PIP/HH IRP Start, middle, and end of each wave CDP and distal latency Contractile vigor (DCI) Peristaltic breaks/failure Bolus clearance Changes across maneuvers

12 Analysis Wang YT. J Neurogastroenterol Motil Conklin JL. J Neurogastroenterol Motil 2013.

13 Analysis Conklin JL. J Neurogastroenterol Motil 2013.

14 Chicago Classification v3.0 Kahrilas PJ, et al. Neurogastroenterol Motil 2015.

15 Findings outside CC Impedance Achalasia with normal IRP UES/Striated esophagus changes TLESR s/rumination/supragastric belching

16 Findings outside CC Ravi K, Katzka DA. Amer J Gastroenterol 2016.

17 Achalasia Pandolfino JE, et al. Gastroenterology 2008.

18 Analysis UES Hypertensive Hypotensive Upper esophagus Hypotensive Wang YT. J Neurogastroenterol Motil 2012.

19 Diagnoses outside CC TLESR Rumination Supragastric Belching Conklin JL. J Neurogastroenterol Motil 2013.

20 Clinical management Remember this is a technical study! Relationship between findings and clinical story is essential Eg. Opiate use can mimic type III achalasia Ravi K, et al. Dis Esophagus 2016.

21 IEM Can be normal per CC 20-58% of all EM diagnoses Failed swallows potentially more relevant Scheerens C, et al. United European Gastroenterol J Gyawali CP. Neurogastroenterol Motil Jain A, et al. Neurogastroenterol Motil 2018.

22 IEM Multiple rapid swallows enhances utility Min YW, et al. Medicine (Baltimore) Mello MD, et al. Neurogastroenterol Motil 2016.

23 IEM Treatment Lifestyle modifications Chew well Decrease bolus consistency; liquids with every bite Stay upright at meals Pharmacotherapy GERD treatment Prokinetics Buspirone Scheerens C, et al. United European Gastroenterol J 2015.

24 IEM Goldberg MB, et al. Innovations (Phila) 2016.

25 EGJOO Rule out structural disease: EGD +/- EUS Fundoplication Hernia Stricture EoE Cancer Infiltrative disease Unclear clinical significance when functional

26 EGJOO Treatment does not affect 3y clinical outcome Increased symptom persistence if: dysphagia is presenting symptoms or with higher IRP/DCI Schupack D, et al. Neurogastroenterol Motil 2017.

27 EGJOO Distinguish from achalasia Theory of the early achalasia variant Bolus clearance assessment is useful Consider barium swallow with tablet Consider repeat study at a later date Zizer E, et al. Z Gastroenterol Pandolfino JE, Gawron AJ. JAMA 2015

28 Take-Home Points Many steps go into the analysis of a manometric study Don t just trust the numbers Chicago classification covers a lot but not everything; other findings may lead to the correct diagnosis Clinical correlation is essential to appropriate interpretation of manometric findings

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