Esophageal MotorAbnormalities

Brooks D.Cash,MD,FACP,AGAF,FACG,FASGEProfessorofMedicineGastroenterologyDivisionUniversityofSouthAlabamaMobile,AL

HighResolutionManometryPivotalAdvance

• LateRayClouse,MD– Suspectedwidelyspacedrecordingpointsfromwaterperfusedsystemsweremissingimportantdata

– Developedspatiotemporalcontourplotsandconvertedamplitudestocolors

– Softwaredevelopedtoprovide“bestfit”databetweensensors

– Solidstatecatheterswith36high‐fidelitycircumferentialsensors• Entireesophaguscouldnowbevisualized

– Additionalrefinements(3DHRM,impedance,video)andapplications(anorectal,gastricandsmallbowel)

EsophagealPressure Topography• High‐ResolutionManometry Catheter

• Spansfromthepharynxtothestomachwithsensorseparationofnomorethanacentimeterwithinandaroundthesphincters.

– Greaterthan32pressuresensors– Temporalfrequencyresponsematchedtothezoneoftheesophagus

• Comparedtowaterperfusion,theimmediateadvantagesofHRMare:– 1)simplifiedproceduralsetupwithimprovedsphincterlocalization– 2)eliminationofmovementartifact– 3)simplifieddatainterpretation– 4)abilitytoperformmoresophisticatedanalysisofesophagealfunction.

Each sensor has 12 pressure sensitive segments

Sierra Scientific Instruments Medical Measurement Systems Sandhill Scientific Inc.

Manometric port

40

mmHg0

0 2.5 4.5 5.6 7.1 8.5 13.08.8 11.0

Functional Imaging ofEsophageal PeristalsisHIGH‐RESOLUTION MANOMETRY

ClousePlot

Manometric port

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0 2.5 4.5 5.6 7.1 8.5 13.08.8 11.0

TrueFunctional Imaging ofEsophageal PeristalsisESOPHAGEAL PRESSURE TOPOGRAPHY

‐10

10

30

70

90

≥110

50

Pressure mmHg

Clouse Plot

Pressure Topography ofEsophagealMotility:Whatdoesitadd?

•Moreakintoanimagingmodality– Definesimportantanatomicallandmarksandabnormalities

– Refinesmeasurementofimportantmotorevents• EGJrelaxation• Peristaltictimingvelocity• Contractileactivity/force/amplitude

– Definesintra‐luminalpressurizationpatterns– Permitspatternrecognition

3MainStepsinDiagnosticApproachtoaHighResolutionManometry Test

1. AssessEGJanatomyandfunction2. Assessesophagealbodyfunction3. Reviewpressurizationpatterns

These3stepswillpermitdiagnosisofmostesophagealmotorabnormalities

*SomechangesinprioritizationwithrecentChicagoClassificationupdate(v3.0)

AnatomyofaHighResolutionEsophagealManometry Test

STEP 1| Assess the EGJ Anatomy and Function

• Determine ifhiatus hernia is present• Confirm that the catheter has crossed the EGJand diaphragm

Integrated relaxation pressure: The IRP will determine whetheroutflow obstruction at the EGJis evident. Disorders are separatedatthis point, determined by those with or without outflowobstruction at the EGJ.

DEEP BREATH

3

Integrated Relaxation Pressure (IRP): Mean EGJpressure measured withasleeve for 4 contiguous or non‐contiguous seconds of relaxation in the10‐second window following deglutitive UES relaxation.

• The upper limit of normal using ManoScan is 15mmHg.

IRP INTEGRATED RELAXATIONPRESSURE

IRP INTEGRATED RELAXATIONPRESSURE

Assess the EGJ Anatomy and Function

STEP 2 | AssessEsophageal Body Function

• Peristaltic integrity: either intact, weak or failed• Contractile deceleration point (CDP): anatomic separationpoint (between tubular esophagus and phrenic ampulla)

• Distal Latency (DL): timing of esophageal peristalsis• will define the swallow as premature or normal latency

• Distalcontractileindex(DCI):vigorofthedistalesophagealcontraction

• Contractile front velocity (CFV):speedofesophagealcontractions

• previouslyused to define rapid contraction• nolongerconsideredmeaningful

Peristaltic Breaks: Gaps in the 20 mmHg isobaric contour of theperistaltic contraction between the UES and EGJ, measured in axial length.

LARGE BREAK

FAILEDSWALLOW

Contractile Deceleration Point (CDP): The inflection point along the 30 mmHgisobaric contour where propagation velocity slows, demarcating the tubular esophagus fromthe phrenic ampulla.

Distal Latency (DL): Interval between UES (1) relaxation and the CDP (2), expressed inseconds. Normal DL is >4.5 sec.

CDP CONTRACTIONDECELERATION POINT(2)

UES RELAXATION (1)

CDP CONTRACTIONDECELERATION POINT(2)DL DISTAL LATENCY

CDP CONTRACTIONDECELERATION POINT(2)

DL: 7.8 sec

STEP 3 | Pressurization PatternsEach swallow should be evaluated using the IBC tool to document an isobaric pressurization above 30 mmHg.

Achalasia: HRMled to the identification of three discernible achalasia types. Each subgrouprepresents adistinct clinical entity, each with significantly different biomechanics andtreatment outcomes. Type I patients do significantly better with Heller myotomy than withpneumatic dilatation, and Type IIIpatients exhibit the worst prognostic outcome.

Achalasia TYPEI

There is no significant pressurization within the body of the esophagus.Therefore, this would be classified as failed peristalsis with abnormal IRP. In theabsence of esophageal body contractility, the IRP threshold of >10 mmHg is usedto distinguish Type I Achalasia from absent peristalsis.5

Failed peristalsis with abnormal IRP - no esophageal function

MajorDisordersofEsophagealPeristalsis

• Achalasia• HypertensiveLES/EGJOutflowobstruction• (Nutcrackeresophagus)• Jackhammeresophagus• Distalesophagealspasm(DES)• Absentperistalsis

Pressure Topography ofEsophageal MotilityThe Chicago Classification

Neurogastroenterology and Motility, 2015;27;160‐74.

ChicagoClassification3.0Changes• UsemedianratherthanmeancutoffvalueforIRP• UselowerIRPcutofffortypeIachalasia(platformspecific)• Panesophageal pressurizationwith≥20%swallowswith100%failedcontractionsistypeIIachalasia irrespectiveofIRP

• EmphasizeheterogeneityofconditionspotentiallycausingEGJoutflowobstruction

• Modifyhypercontractile esophagusto≥20%swallowswithDCI>8000mmHgxsxcm

• Substitute‘absentcontractility’for‘aperistalsis’or‘absentperistalsis’todifferentiatefromotherscenarioswhereperistalsis isabsent(e.g.,achalasia)

• Rename‘minordisordersofperistalsis’• Eliminatesmallbreaks(2–5cm)inthe20‐mmHgisobariccontourasacriterionofabnormality

• EliminaterapidCFV(>9cm/s)asacriterionofabnormality• Eliminatethedesignationof‘hypertensiveperistalsis’(DCI5000–8000mmHgxsxcm)(nomoreNutcracker)

• Adoptthe‘ineffectiveesophagealmotility’(IEM)designationfromconventionalmanometry

• Eliminate‘frequentfailedperistalsis’asadistinctdiagnosticentity

• IncorporatenewdatafromstudiesofmultiplerepetitiveswallowsintothecriteriaforIEM

ChicagoClassification3.0Changes

EGJOutflowObstruction• Incompletelyexpressed

achalasia• Mechanicalobstruction

IRP≥upperlimitofnormalAND

someinstancesofintactorweakperistalsis Yes

Achalasia• SubtypeI:Nocontractility• SubtypeII:≥ 20%PEP• SubtypeIII:≥20%spasm

(DL<4.5s)

IRP ≥ULN AND100%failed peristalsis or

spasm Yes

No

Neurogastroenterology and Motility, 2015;27;160‐74.

DisorderswithEGJOutflowObstructionThe Chicago Classification

Achalasia• Dysphagia,wt loss,regurgitation,halitosis,GERDsxs

• Immune‐mediateddiseasetargetingesophagealmyenteric plexus(neuronsandganglia)– Antineuronal Abs,inflammatorycells,cytokines,immunoglobulins,complement

– Achalasiasubtypesmayrepresentdifferentialdegreeofimmuneactivation/selectivity(cellvshumoral)

– HSV‐1implicatedastriggerKahrilas PJ,etal.Gastroenterology2013;145:954‐66.

100

50

0

mmHg150

30

Type I Type II Type III

IRP= 22.3 mmHg IRP= 24.2 mmHg IRP= 29.8 mmHg

air

liquid

air

EGJ

EGJ EGJ

5 seconds 5 seconds 5 seconds

High‐Resolution Manometry: Achalasia subtypes

contraction

diverticulum

ClinicalEvolution of AchalasiaAssessing clinically relevantphenotypes

Early Type II or III

Late Type I

Chronic Type II/III‐‐I

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AchalasiaMimics

• Malignancy(Pseudoachalasia)• Chaga’s disease• Amyloidosis• Postvagotomy• Neurofibromatosis• Sarcoidosis• MENIIb