Esophageal Esophageal ManometryManometry

Chhaya Hasyagar, MDChhaya Hasyagar, MD

GastroenterologyGastroenterology

Kaiser, SacramentoKaiser, Sacramento

ObjectivesObjectives

Review esophageal anatomyReview esophageal anatomy Role of esophageal manometry Role of esophageal manometry

testingtesting Review manometry tracingsReview manometry tracings

AnatomyAnatomy

18- to 25-cm long 18- to 25-cm long muscular tube muscular tube

cervical and cervical and thoracic parts.thoracic parts.

wall is composed of wall is composed of striated muscle in striated muscle in the upper part, the upper part, smooth muscle in smooth muscle in the lower part, and the lower part, and a mixture of the two a mixture of the two in the middle.in the middle.

Esophageal MotilityEsophageal Motility

Three separate stages:Three separate stages:– Voluntary or oral stage.Voluntary or oral stage.– Pharyngeal stage.Pharyngeal stage.– Esophageal stage.Esophageal stage.

Esophageal MotilityEsophageal Motility

Esophagus Diagnostic Esophagus Diagnostic proceduresprocedures Morphologic diagnosticsMorphologic diagnostics

– Esophageal radiographyEsophageal radiography– EndoscopyEndoscopy– Pill cam ESO Pill cam ESO

Functional diagnosticsFunctional diagnostics– Esophageal manometryEsophageal manometry– Esophageal pH monitoringEsophageal pH monitoring– Esophageal impedanceEsophageal impedance– Radionuclide 99 mTC scintiscanningRadionuclide 99 mTC scintiscanning

Esophageal Esophageal ManometryManometry

When does it help?When does it help?– Functional disorder is suspectedFunctional disorder is suspected– Unrevealing morphological studiesUnrevealing morphological studies– Part of pre-operative evaluationPart of pre-operative evaluation

Water Perfused Water Perfused SystemSystem

Water Perfused Water Perfused SystemSystem AdvantagesAdvantages

– Cost effectiveCost effective– Flexibility in configurationFlexibility in configuration

DisadvantagesDisadvantages– Slow response rateSlow response rate– Less suitable for UES and pharynxLess suitable for UES and pharynx– Need for skilled personnel for use Need for skilled personnel for use

and maintenance and maintenance

Solid state CathetersSolid state Catheters

Catheters have Catheters have miniature strain gauge miniature strain gauge transducers built into transducers built into the catheter to the catheter to generate electrical generate electrical output signalsoutput signals

Solid State CathetersSolid State Catheters

AdvantagesAdvantages– Fast responseFast response– No water perfusionNo water perfusion– Easy to use and calibrateEasy to use and calibrate

DisadvantagesDisadvantages– ExpensiveExpensive– Limited number sensorsLimited number sensors– FragileFragile– Functional lifespanFunctional lifespan

Esophageal Esophageal ManometryManometry Three steps:Three steps:

– LESLES– BodyBody– UESUES

Esophageal Esophageal ManometryManometry

ManoScanManoScan™™ / HRM / HRM OverviewOverview

Automatically captures Automatically captures all motor function from all motor function from pharynx to stomachpharynx to stomach

Reduces data Reduces data acquisition times by acquisition times by more than 60%more than 60%

Simplifies procedures Simplifies procedures and technician trainingand technician training

Yields portable & Yields portable & reproducible data setsreproducible data sets

Normal Study UsingNormal Study Using ManoScanManoScan™™ Line Trace Line Trace ModeMode

UES

LES

Normal studyNormal study

Case 1Case 1

48 year old female with long 48 year old female with long standing heartburnstanding heartburn

Symptoms well controlled on PPIs Symptoms well controlled on PPIs for 5 yearsfor 5 years

Now with recurrence of symptoms Now with recurrence of symptoms despite high dose PPI despite high dose PPI

EGD: hiatal hernia otherwise EGD: hiatal hernia otherwise normal normal

Esophageal Esophageal manometrymanometry

24 hour pH confirmed acid reflux24 hour pH confirmed acid reflux Proceeded with surgery for Proceeded with surgery for

management of GERDmanagement of GERD

Case 2Case 2

36 year old archeologist with gradual 36 year old archeologist with gradual onset of fatigue and dysphagia. onset of fatigue and dysphagia.

Difficulty with drinking waterDifficulty with drinking water Returned from a trip to the Amazon Returned from a trip to the Amazon

basin 6 months agobasin 6 months ago EGD: Normal except for a “pop” felt EGD: Normal except for a “pop” felt

while advancing scope into the stomachwhile advancing scope into the stomach Next step?Next step?

HREMHREM

Aperistalsis in the Aperistalsis in the smooth muscle smooth muscle portion of the body of portion of the body of the esophagus. the esophagus.

elevated resting LES elevated resting LES pressure: >45 mmHgpressure: >45 mmHg

incomplete LES incomplete LES relaxation after a relaxation after a swallowswallow

““common channel common channel effect”effect”

AchalasiaAchalasia

Bird beak appearance

Dilated esophagus

AchalasiaAchalasia

Idiopathic or acquired – Chagas Idiopathic or acquired – Chagas diseasedisease

Increases risk of squamous cell Increases risk of squamous cell CACA

Chagas disease – parasite Chagas disease – parasite Trypanosoma cruzi, transmitted Trypanosoma cruzi, transmitted by “kissing bug”by “kissing bug”

Achalasia - Achalasia - ManagementManagement Endoscopic:Endoscopic:

– botulinum toxin botulinum toxin injection of LES, injection of LES, pneumatic pneumatic dilation of LESdilation of LES

Surgical:Surgical:– Hellers myotomy Hellers myotomy

(usually with anti-(usually with anti-reflux reflux fundoplication)fundoplication)

Case 3Case 3

50 year old female seen in the ER 50 year old female seen in the ER 4 times with sudden onset of 4 times with sudden onset of chest pressure.chest pressure.

Cardiac workup including stress Cardiac workup including stress test was negativetest was negative

EGD: normalEGD: normal Next step?Next step?

Diffuse esophageal Spasm Diffuse esophageal Spasm (DES)(DES)

Frequent simultaneous contractions (>20-30%) with interval Frequent simultaneous contractions (>20-30%) with interval normal contractions.normal contractions.

Confined distal 2/3.Confined distal 2/3. Multiphasic waves.Multiphasic waves. Prolonged duration.Prolonged duration. Spontaneous contractionsSpontaneous contractions High amplitude of the contractionsHigh amplitude of the contractions

DESDES

Rosary Bead or Rosary Bead or corkscrew corkscrew esophagusesophagus

Treatment: Treatment: – CCB (diltiazem) CCB (diltiazem) – nitrates nitrates

(isosorbide) (isosorbide) – Sildenafil Sildenafil – TCA (imipramine)TCA (imipramine)

Nutcracker EsophagusNutcracker Esophagus

high amplitude high amplitude peristaltic contractions peristaltic contractions in the distal 10 cm of in the distal 10 cm of the esophagusthe esophagus

average distal average distal esophageal peristaltic esophageal peristaltic pressures >220 pressures >220 mmHg mmHg

Increased distal Increased distal peristaltic duration peristaltic duration (mean value >6 sec) (mean value >6 sec)

Case 4Case 4

55 year old female with intolerance to cold, heartburn not 55 year old female with intolerance to cold, heartburn not responding to medications, with c/o dysphagia to solids for 8 responding to medications, with c/o dysphagia to solids for 8 monthsmonths

Wears gloves in summer as her fingers turn blue to purple in Wears gloves in summer as her fingers turn blue to purple in AC roomsAC rooms

Upper endoscopy: normal, no webs or ringsUpper endoscopy: normal, no webs or rings Next step?Next step?

SclerodermaScleroderma

Pathophysiology:Pathophysiology:– alterations of the alterations of the

microvasculature, microvasculature, the autonomic the autonomic nervous system, nervous system, and the immune and the immune system, leading system, leading to fibrosis to fibrosis

– Affects lower 2/3 Affects lower 2/3 of esophagusof esophagus

Esophageal impedanceEsophageal impedance

Measures changes in resistance to Measures changes in resistance to alternating electrical current when a alternating electrical current when a bolus passes through a ringbolus passes through a ring

Liquid containing boluses will lower Liquid containing boluses will lower the impedance to a nadir valuethe impedance to a nadir value

Gas will produce a rapid rise in Gas will produce a rapid rise in impedanceimpedance

Esophageal ImpedanceEsophageal Impedance

Esophageal motility Esophageal motility disordersdisorders

Primary disordersPrimary disorders– AchalasiaAchalasia– Diffuse esophageal spasmDiffuse esophageal spasm– Nutcracker esophagusNutcracker esophagus– Ineffective motility disorderIneffective motility disorder

Secondary disordersSecondary disorders– SclerodermaScleroderma

Disclosure: noneDisclosure: none QuestionsQuestions