DYSPHAGIA - THE ROLE OF OESOPHAGEAL MOTILITY DISORDERS

IAN WALLACE FCP(SA), FRACP.SHAKESPEARE SPECIALIST GROUP

MILFORD, AUCKLAND

CAUSES OF DYSPHAGIA

Stages of swallowing

Oropharyngeal (Voluntary)

Oesophageal (Involuntary)

CAUSES OF DYSPHAGIA

HISTORY Oropharyngeal vs oesophageal body Duration and frequency (progressive?) Associated regurgitiation Associated reflux symptoms Solids to liquids vs solids and liquids

EXAMINATION Lymphadenopathy Neurological

CAUSES OF DYSPHAGIA

Structural abnormalities Oesophageal neoplasm Peptic stricture Shatzki ring Incarcerated hiatal hernia Oesophageal web Oesophageal diverticulae

CAUSES OF DYSPHAGIA

Motility disorders Non specific motility disorder

(ineffective oesophageal motility) Achalasia Eosinophilic oesophagitis Nutcracker oesophagus Diffuse oesophageal spasm Hypertensive LOS

CAUSES OF DYSPHAGIAMOTILITY DISORDERS Dig Dis Sci 1987;32:583

Dysphagia in 132 patients

NSMD

nutcracker

DOS

HLOS

Achalasia

CAUSES OF DYSPHAGIAMOTILITY DISORDERS

Special investigations Baseline bloods CXR Endoscopy and mucosal biopsy Barium swallow (marshmallow) Oesophageal manometry

Normal Swallow

32 Pressure Channels

High ResolutionImpedance-Manometry

8

9

10

5

32

11

12

13

14

15

16

17

18

19

20

21

22

23

7

1

0

24

25

26

27

-1

-2

-3

-4

-5

-6

6

28

29

4

Impedance Technology Fundamentals

Alternating Current Generator

Current Generat

or

Impedance Technology Fundamentals

Reflux Bolus Conducts Electricity&

Current Flows Between Impedance Rings

Current Generat

or

Impedance Technology Fundamentals

High Impedance

No Reflux

Low Impedance

Reflux

A single impedance channel will detect bolus movement through the oesophagus

Multiple impedance channels are required to detect the direction of bolus movement

Impedance Technology Fundamentals

123456

Pressure

Impedance

Contour Plot View of Swallow with Normal Manometry & Complete Bolus Transit

Esophageal Body

Pharynx

UES

Esophageal Body

LES

Gastric

123456

Pressure

Manometry Waveforms

Bolus Transit Waveforms

Impedance

Contour Plot View of Swallow with Normal Manometry & Complete Bolus Transit

Impedance

Time

Impedance Contacts

Impedance Contacts

Impedance Technology Fundamentals

Bolus Entry Bolus Exit

Bolus Present

OESOPHAGEAL MOTILITY DISORDERSINEFFECTIVE OESOPHAGEAL MOTILITY

Common in patients with chronic reflux Predictive of refractory nocturnal GORD Characterized by a hypo contractile

oesophagus. (amplitude <30mmHg in >30% of contractions)

Failure of distal propagation of peristaltic wave

Oesophageal Motility Disorders Achalasia-Aetiology

Idiopathic- 98 % Primary Secondary

Familial Associated with other congenital

defects Associated with degenerative

neurological disease

Oesophageal Motility Disorders Achalasia - Symptoms

Dysphagia – usually slowly progressive

Regurgitation Chest pain and dysphagia Reflux symptoms

Oesophageal Motility Disorders Achalasia-Manometric features

Normal to raised LOS resting pressures

LOS fails to relax to gastric baseline Raised residual pressures Raised oesophageal baseline

pressures Absent or chaotic low amplitude

simultaneous peristalsis

Normal Swallow

Achalasia Tracing

Oesophageal Motility disorders Achalasia-Treatment

Pneumatic dilatatation Risks Patient selection

Botox injection Patient selection

Surgery Gastro-oesophageal reflux a

significant complication

Eosinophilic Esophagitis Definition:

Presence of eosinophils in the squamous epithelium or deeper

Number of Eosinophils/hpf ranged from 30 – 320 (mean 101)

Various studies have used 15-30/hpf Oesophagus - an immunologically active

organ Eosinophilic infiltration also seen in :

GORD Eosinophilic gastroenteritis Collagen vascular diseases Infections

Allergy Profile

Allergy history 90% Atopic illness 46% Food allergy 25% Family history of asthma

43% Blood eosinophils 36% IgE 56% Positive RAST 42%

Endoscopic features associated with EENonerosive changes extending along the whole esophagus

• Whitish pinpoint exudate or papules

• Granularity • Loss of vascular pattern • Linear furrow and fold pattern • Rings • Corrugation

Focal stricture (often proximal)

Long-segment stricture (small caliber esophagus)

Linear sheering of mucosa after dilation

Eosinophilic OesophagitisTreatment Options

Acid suppression (PPI therapy) where there are reflux symptoms PLUS:

Swallowed inhalers – e.g. fluticasone Antihistamine therapy (Loratidine) Corticosteroids

Elimination diets where specific allergies are defined

Role of Ranitidine Clin Gastro. And Hepatol.2004;2:523 - 530

Eosinophilic Oesophagitis - Conclusion

EE, a condition seen in children now increasing identified in adults

Should be considered in the relevant patient population & those not responding to standard reflux treatment

Awareness and recognition of gross changes by endoscopists

Importance of tissue sampling for subtle abnormalities

Establishing correct diagnosis may prevent unnecessary interventions, e.g. fundoplication

OESOPHAGEAL MOTILITY DISORDERSNUTCRACKER OESOPHAGUS

Most common cause of NCCP in those patients with an oesophageal motility disorder.

Average distal pressures > 180 mm Hg.

Peristalsis is normal so Ba studies usually normal.

90% present with chest pain.

Normal Swallow

Nutcracker Oesophagus

DYSPHAGIACONCLUSIONS

The symptom of dysphagia does not always indicate a physical obstruction

Oesophageal motility disorders account for the majority of cases of dysphagia

A normal endoscopy or Ba study does not exclude a motility disorder - role of oesophageal manometry

Importance of mucosal biopsies of macroscopically normal mucosa