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Esophageal Manometry Kevin Kolendich, MD Gastroenterology and Hepatology Missoula Medical Conference October 24 th , 2014. Financial Disclosures. No financial disclosures. http://monkeyartawards.typepad.com/.a/6a00e55097ba24883401053619f88f970b-800wi. A Little Background on Me.

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Esophageal ManometryKevin Kolendich, MDGastroenterology and HepatologyMissoula Medical ConferenceOctober 24th , 2014


Financial disclosures
Financial Disclosures

No financial disclosures

http://monkeyartawards.typepad.com/.a/6a00e55097ba24883401053619f88f970b-800wi



St patrick hospital
St. Patrick Hospital

St. Patrick Hospital is a 213-bed hospital with a level 2 trauma center. St. Patrick currently has 1,400 employees and 266 physicians.


St patrick hospital1
St. Patrick Hospital

  • St. Patrick Hospital Motility Team.

    • Jenifer Alsbury, RN

    • Tamara Keogh, RN

    • Christi Brinda, RN

  • High volume motility center.


Esophageal manometry

Esophageal Manometry


Esophageal manometry definition
Esophageal ManometryDefinition

A diagnostic test in which a thin tube is passed into the esophagus to measure the pressures exerted by the muscles of the esophagus over time during a swallow.


Is this how esophageal manometry appears to you
Is this how esophageal manometry appears to you?

http://timothystotz.com/wp-content/uploads/2013/05/flowering-staircase-timothy-stotz.jpg


Once understood manometry is so simple that anyone can do it
Once understood, manometry is so simple that anyone can do it

http://weaponsman.com/wp-content/uploads/2013/12/DogOpeningDoor.jpg

http://2.bp.blogspot.com/_BrhJY2UGYrE/S8zk98lUGOI/AAAAAAAAADU/jWC4zHes7LY/s400/Farside+-+pull.jpg



Learning objectives
Learning Objectives

  • Describe normal esophageal anatomy.

  • Understand the difference between water perfused manometry and solid state esophageal manometry.


Learning objectives1
Learning Objectives

  • Be able to properly identify and mark the following anatomic landmarks using high resolution manometry.

    • The upper esophageal sphincter (UES)

    • The esophageal body

    • The esophago-gastric junction (EGJ)

  • Be able to describe patient preparation for esophageal manometry.


Learning objectives2
Learning Objectives

  • Be able to describe how an esophageal motility catheter is placed.

  • Understand when to refer patients for esophageal manometry.

  • Know where to find resources to further your understanding of manometry.



Normal esophageal anatomy
Normal Esophageal Anatomy

http://www.webmd.com/digestive-disorders/picture-of-the-esophagus


Normal esophageal anatomy1
NormalEsophageal Anatomy

  • Upper Esophageal Sphincter (UES)

    • Cervical esophagus

    • Cricopharyngeus

    • Inferior pharyngeal constrictor

http://classconnection.s3.amazonaws.com/231/flashcards/1157231/jpg/pharyngeal-muscles1328499814983.jpg


Normal esophageal anatomy2
Normal Esophageal Anatomy

  • Esophageal body

    • The proximal 5% is striated muscle.

    • The middle 35%-40% is mixed (transition zone).

    • The distal 50%-60% is entirely smooth muscle.

http://www.christinas-home-remedies.com/image-files/esophagus-anatomy.jpg


Normal esophageal anatomy3
Normal Esophageal Anatomy

  • Muscular composition

    • Outer layer (longitudinal).

    • Inner layer (circular).

      • more precisely helical muscle.

http://www.nature.com/gimo/contents/pt1/full/gimo6.html


Clinical correlation
Clinical Correlation

  • Clinical Correlation:

    • Presbyesophagus also known as tertiary contractions

http://upload.wikimedia.org/wikipedia/commons/f/ff/Korkenzieher-%C3%96sophagus.jpg


Normal esophageal anatomy4
Normal Esophageal Anatomy

  • There are three major contributors to the EGJ high pressure zone.

    • 1. The LES

    • 2. The crural diaphragm

    • 3. The muscular architecture of the gastric cardia

http://www.nature.com/gimo/contents/pt1/images/gimo14-f1.jpg


Understand the difference between water perfused manometry and solid state esophageal manometry


Manometry
Manometry

  • Water Perfusion Manometry

    (Conventional).

    • Every 5 cm

  • Solid State Manometry (High Resolution, 3D).

    • Every 1 cm

http://www.upmc.com/patients-visitors/education/PublishingImages/G-L/EsophManometry-1.jpg


Equipment conventional manometry
Equipment – Conventional Manometry

  • 8 channels, 4 are located 5 cm from the tip of the catheter with 4 other more proximal sensors spaced 5 cm apart.

  • 3.9 mm diameter.


Conventional manometry
Conventional Manometry


Equipment high resolution manometry
Equipment – High Resolution Manometry

  • All sensors are truly circumferential .

  • 36 channels spaced 1 cm apart 12 pressure sensing points at each channel (432 data points) .

  • Small diameter

    2.75 mm.

Source: http://www.sierrainst.com/manoscan360.html


High resolution manometry
High Resolution Manometry

  • Magenta end of color spectrum

    (hot colors) = highest pressure.

  • Blue end of color spectrum

    (cool colors) = lowest pressure.



Discuss the advantages high resolution manometry has over conventional esophageal manometry

Discuss the advantages high resolution manometry has over conventional esophageal manometry.


High resolution manometry vs conventional manometry
High Resolution Manometryvs. Conventional Manometry

Conventional

Manometry

High Resolution Manometry

Catheter stays in one position

Solid state systems are relatively simpleand less cumbersome

High fidelity

Color contour

No need for pull through: software creates an electronic sleeve for LES determination

Hiatal hernias are easily identified

Solid state catheters are soft and more comfortable

Procedure takes less time

Array of 36 channels straddle the entire esophagus, sees the entire organ

  • Need to move catheter for LES in most systems

  • Water-perfusion systems are multicomponent and cumbersome

  • Low fidelity

  • Waveforms only

  • LES measurements complex; some use sleeves, others need station pull-through technique

  • Hard to find hiatal hernias

  • Water-perfused catheters are stiff and more uncomfortable

  • Tests take longer

  • Large gaps between channels (5 cm)


High resolution manometry vs conventional manometry1
High Resolution Manometryvs. Conventional Manometry


Patient preparation for high resolution esophageal manometry

Patient Preparationfor High Resolution Esophageal Manometry


Pre pr0cedure counseling
Pre-Pr0cedure Counseling

  • How do you describe esophageal manometry to a patient?

    • During esophageal manometry, a thin, pressure-sensitive, flexible tube is passed through your nose and into your stomach.

    • When the tube is in your esophagus, you will be asked to swallow. The pressure of the muscle contractions will be measured along the length of your esophagus.

    • The tube is removed after the test is completed. The test takes about 1 hour.


Pre pr0cedure counseling1
Pre-Pr0cedure Counseling

  • How do you tell patients to prepare for a manometry?

    • Patients should not have anything to eat or drink for 4-6 hours before the test (varies by center).

    • There is no need for bowel preparation.

    • Take all prescribed medications as usual.

      • This includes anticoagulants, aspirin, and NSAIDs, acid suppressive therapy.


Pre pr0cedure counseling2
Pre-Pr0cedure Counseling

  • How will the test feel?

    • Typically, the test is not uncomfortable.

    • Some patients may experience a gagging sensation when the tube is being placed.


How is an esophageal manometry probe placed

How is an Esophageal Manometry Probe Placed?


Catheter placement
Catheter Placement

  • Before bringing the patient into the room an RN performs a focused H&P and chart review.

    • Indication (dysphagia, chest pain, pre-operative evaluation, etc.)

    • Allergies (assure the patient isn’t allergic to lidocaine)

      • If they are use sterile lubricant jelly

    • Pertinent past surgeries (Nasal, esophageal, bariatric surgery etc.)

  • Make sure the patient did not eat or drink anything for 4 to 6 hours prior to test (this varies by center).


  • Catheter placement1
    Catheter Placement

    • The patient is brought into the procedure room.

    • A gown is placed over their upper body and they sit on the edge of agurney.

    • The patient occludes each nostril and sniffs to determine if their right or left nostril is more patent.

    http://classconnection.s3.amazonaws.com/369/flashcards/1414369/png/assess_patency_of_nostrils1333807384492.png


    Catheter placement2
    Catheter Placement

    • The nostril is numbed with 2% lidocaine jelly using a 6-inch cotton tip applicator.

    • The manometric catheter is lubricated with 2% lidocaine.

    http://jan.ucc.nau.edu/daa/woundproducts/curasolgel3.jpg


    Catheter placement3
    Catheter Placement

    • The patient brings their chin down to their chest.

    • The catheter is advanced through the medicated nostril into the esophagus while the patient swallows.

    https://myhealth.alberta.ca/health/_layouts/healthwise/media/medical/hw/h9991890_001.jpg

    http://www.bartleby.com/107/Images/large/image855.gif


    Catheter placement4
    Catheter Placement

    • The manometric catheter is advanced until it crosses the lower esophageal sphincter and its distal tip is in the stomach.

    • The catheter is secured in place with tape.

    • The patient then lies supine on a gurney.

    http://www.upmc.com/patients-visitors/education/PublishingImages/G-L/EsophManometry-1.jpg


    Catheter placement5
    Catheter Placement

    • 5 ml of water (or saline) is placed into the patient’s mouth using a syringe.

    • The patient holds the liquid in their mouth then swallows once.

    • 30 seconds later this is repeated.

    • 10 wet swallows are performed.

    • The catheter is removed.

    http://www.robertsewellmd.com/Portals/2/Motility%20HD.jpg


    Describe the manometric findings present during a normal swallow. 1. LES relaxation2. Normal esophageal peristalsis3. UES relaxation



    Manometry tracing
    Manometry Tracing

    http://www.nature.com/ajg/journal/v105/n5/images/ajg2010165i1.gif



    Indications
    Indications

    • Dysphagia.

    • Non-cardiac chest pain.

    • Placement of intraluminal devices (e.g. pH probes).

    • Preoperative assessment of patients being considered for anti-reflux surgery and bariatric surgery.

    • Detecting esophageal motor abnormalities associated with systemic diseases (e.g. connective tissue diseases).

    American Gastroenterological Association Patient Care Committee on May 15, 1994


    Dysphagia
    Dysphagia

    • The first step is to distinguish between oropharyngeal dysphagia and esophageal dysphagia.

    • Oropharyngeal dysphagia:

      • Arises from dysfunction of the pharynx and upper esophageal sphincter.

    • Esophageal dysphagia:

      • Arises from disorders of the esophageal body and lower esophageal sphincter.


    Dysphagia1
    Dysphagia

    Oropharyngeal

    Esophageal

    Have difficulty swallowing several seconds after initiating a swallow.

    Localize symptoms to the suprasternal notch or behind the sternum.

    May be associated with a history of food impaction or food “sticking” in the chest.

    • Have difficulty initiating a swallow.

    • Localize symptoms to the cervical region.

    • Frequently associated with coughing, choking, nasal regurgitation, and dysphonia.



    Dysphagia2
    Dysphagia with dysphagia in the office?

    • Do you have problems initiating a swallow or do you feel food getting stuck a few seconds after swallowing?

    • Do you cough or choke or is food coming back through your nose after swallowing?

    • Do you have problem swallowing solids, liquids, or both?

    • How long have you had problems swallowing and have your symptoms progressed, remained stable, or are they intermittent?


    Dysphagia3
    Dysphagia with dysphagia in the office?

    • Could you point to where you feel food is getting stuck?

    • What medications are you using now?

      • potassium chloride

      • alendronate

      • ferrous sulfate

      • quinidine

      • ascorbic acid

      • tetracycline

      • aspirin

      • NSAIDs


    Dysphagia4
    Dysphagia with dysphagia in the office?

    • Upper Endoscopy:

      • Patients with suspected esophageal dysphagia should be referred for an upper endoscopy as the initial test.

      • Structural assessment.

      • Has the advantage that biopsies can be obtained and intervention performed.

    http://endoscopycenterofdelaware.com/assets/uploaded/images/all/UpperEndoscopy.jpg


    Dysphagia5
    Dysphagia with dysphagia in the office?

    • Barium swallow:

      • This is a good second test following a negative upper endoscopy if a mechanical obstruction is still suspected.

        • External compression.

        • B rings (Schatzki ring) can be missed.

        • Zenker’s diverticulum

        • Cricopharyngealbar

      • Structural and functional assessment.

      • Can assess the UES and pharynx more reliably than upper endoscopy.

    http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/media/medical/hw/h9991108.jpg


    Dysphagia6
    Dysphagia with dysphagia in the office?

    • Esophageal Manometry:

      • Motility testing should be performed in patients with dysphagia in whom upper endoscopy is unrevealing and/or an esophageal motility disorder is suspected.

      • Functional assessment.

    http://gastrocure.com/images/Esophageal_Manometry_img_6.jpg


    Case 1
    Case #1 with dysphagia in the office?

    • 47 year old woman with 2 years progressive dysphagia to solids and liquids. After meals she has a sensation of fullness in her chest . She often drinks water to make solid food pass.

    • A recent EGD was normal thus she was referred for esophageal manometry.


    Achalasia type ii
    Achalasia - Type II with dysphagia in the office?

    Mean IRP > upper limits of normal (incomplete LES relaxation)

    Absence of esophageal peristalsis (note: specifics vary for type I, II, and III achalasia)

    Normal


    Case 11
    Case #1 with dysphagia in the office?

    • The patient underwent pneumatic dilation of her LES to 30 mm with marked improvement in her symptoms.

    • Therapeutic options

      • Heller myotomy

      • Pneumatic dilation

      • Botox injection into the LES

      • POEM (Per Oral Endoscopic Myotomy)


    Chest pain
    Chest Pain with dysphagia in the office?

    • An esophageal source of chest pain should be considered only after cardiopulmonary factors have been carefully investigated.

    http://www.merckmanuals.com/professional/multimedia/v891242.html?Ref=t&RefId=gastrointestinal_disorders/esophageal_and_swallowing_disorders/gastroesophageal_reflux_disease_gerd&Plugin=WMP&Speed=256&ItemId=v891242

    http://drsvenkatesan.wordpress.com/tag/plaque-vs-thrombus/


    Chest pain1
    Chest Pain with dysphagia in the office?

    • A patient should first undergo an upper endoscopy and exclusion of GERD.

    • GERD is the most common cause of non-cardiac chest pain.

    • GERD is much more common than an esophageal motility disorder.

    http://trustinfood.org/chest-pain/wp-content/uploads/2012/10/Chest-Pain-After-Eating.jpg


    Case 2
    Case #2 with dysphagia in the office?

    • A 84 year old male complains of severe chest pain which onsets during meals.

    • EGD, CT abd/pelvis, barium esophagram, and 24 hour ph study are all normal. A cardiac work-up and which includes a nuclear perfusion test is normal. He is told by an ER physician that his symptoms are stress induced and “in his head”.

    • The patient is referred by his PCP for esophageal manometry.


    Jackhammer esophagus
    Jackhammer Esophagus with dysphagia in the office?

    DCI > 8,000 mmHg-cm-s (hypercontractile esophagus)

    Normal mean IRP (the EGJ relaxes normally)


    Case 21
    Case #2 with dysphagia in the office?

    • He initially is treated with diltiazem which causes intolerable hypotension and orthostasis. This medication is stopped and he undergoes EGD with botox injection into the LES with complete resolution of his symptoms.

    • Therapy

      • Rule out EGJ outflow obstruction causing reactive hypercontractile peristalsis

      • Treat GERD if present

      • Calcium Channel blockers (Diltiazem)

      • Nitrates (Isosorbidedinitrate)

      • Sildenafil

      • Botox injection into the LES


    Prior to anti reflux surgery
    Prior to Anti-reflux Surgery with dysphagia in the office?

    • The most important role of esophageal manometry in patients with GERD has traditionally been for evaluation prior to antireflux surgery.

    http://en.wikipedia.org/wiki/Nissen_fundoplication


    Prior to anti reflux surgery1
    Prior to Anti-reflux Surgery with dysphagia in the office?

    Why is esophageal manometry done prior to esophageal or gastric surgery?


    Prior to anti reflux surgery2
    Prior to Anti-reflux Surgery with dysphagia in the office?

    • Manometry may lead to a modification of the surgical approach.

    www.wehealny.org


    Prior to anti reflux surgery3
    Prior to with dysphagia in the office? Anti-reflux Surgery

    • Esopahgealmanometrymay lead to an alternative diagnosis such as scleroderma or achalasia.

    http://www.nature.com/gimo/contents/pt1/images/gimo20-f4.jpg


    Prior to anti reflux surgery4
    Prior to Anti-reflux Surgery with dysphagia in the office?

    • Evaluation of post operative symptoms.

    • The best way to determine if a surgery is causal of a manometric abnormality is comparison of a patient’s pre-operative manometry study to their post-operative manometry study.


    Case 3
    Case #3 with dysphagia in the office?

    • 42 year old woman with long standing heartburn which has had relatively little improvement despite trials of omeprazole, esomeprazole, and dexlansoprazole.

    • Upper endoscopy reveals a small sliding hiatal hernia with LA class A erosive esophagitis.

    • She is referred to a surgeon for consideration of fundoplication. Her surgeon orders pre-operative esophageal manometry and pH testing.


    Jackhammer esophagus1
    Jackhammer Esophagus with dysphagia in the office?

    DCI > 8,000 mmHg-cm-s (hypercontractile esophagus)

    Normal mean IRP (the EGJ relaxes normally)


    Case 31
    Case #3 with dysphagia in the office?

    • The patient was treated for a hypercontractile esophageal disorder with a calcium channel blocker with a significant reduction in symptoms.


    Case 4
    Case #4 with dysphagia in the office?

    • A 49 year old woman with GERD complains of severe heartburn. This improves with twice daily PPI therapy and lifestyle modification, however severe nocturnal symptoms persist.

    • EGD reveals a hiatal hernia and LA class C esophagitis despite compliance with BID PPI.

    • She is referred to a surgeon for consideration of fundoplication. Her surgeon orders pre-operative esophageal manometry and pH testing.


    Weak peristalsis with large peristaltic defects
    Weak Peristalsis with Large with dysphagia in the office? Peristaltic Defects

    1. Normal mean IRP (normal EGJ relaxation)

    2. > 20% of swallows with large (> 5 cm) breaks in the 20 mmHg isobaric contour.

    Normal


    Case 41
    Case #4 with dysphagia in the office?

    • Ambulatory reflux monitoring revealed an 12% incidence of acid reflux despite compliance with PPI therapy with an elevated DeMeester score.

    • The patient underwent Toupet fundoplication. Her symptom of heartburn has resolved and she is now off PPI therapy.

    • Her only concern post-operatively bloating and an inability to belch.



    Further education
    Further Education of

    • If you are interested in further education consider reading the following text.

    • American Neurogastroenterology and Motility Society.


    References
    References of

    • Conklin, J., Pimentel, M., Soffer, E. Color Atlas of High Resolution Manometry. Springer (2009)

    • Kahrilas, Peter J. et al. Esophageal Motility Disorders in Terms of Pressure Topography. J ClinGastroenterol 2008;42:627-635

    • Lin, Henry C. High Resolution Esophageal Manometry. Core Curriculum Conference, The University of New Mexico. 2008, 2011.


    Contact information kevin kolendich md western montana clinic 406 329 7169

    Contact Information: of Kevin Kolendich, MD

    Western Montana Clinic

    (406) 329-7169

    Thank You


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