During this 20-25 minute pre-recorded lecture, Dr. Barry Jaffin discusses the topic of motility disorders of esophagus. This in-depth review will provide an update on this topic for your clinical practice as well as supplement your learning for the ABIM Gastroenterology and Hepatology boards. CME pre-requiste of live Q & A webinar, 8th Annual Mount Sinai Intensive Board Review in Gastroenterology & Hepatology on Sept 22.
Hello this is barry Jackson. I'd like to thank the department of gastroenterology for us to me to speak today on gi motility disorders. To begin with the question always comes up when to consider high resolution geometry as part of the work up. And how will this help you answer some board review questions? Well if you suspect major motor disorders of the esophagus such as a Malaysia. If you want to evaluate the presence of peristaltic function. If you want to explain the nature of symptoms of esophagus. If you want to evaluate the post my ah to me or postponed application patient in considering now of the endo flip which is a functional Luminal imaging probe and to determine the location of the lower esophageal sphincter part of placing a ph probe in the disorders of the esophagus can be broken down very easily using the Chicago classification. The first thing we do is discuss or evaluate the E. G. Junction pressures and that's called the I. R. P. Or uh integrated relaxation pressure. The next we look at major motility disorders and we base that on the D. C. Or distal contract. I'll integral which is a combination of the length of the contraction, the duration of the contraction, the amplitude of the contraction and also at the D. L. Or distill agency as to when the contraction begins after fringe of contractions. And finally we look to see if this break in the parasol tick wave which we can use to classify as major reminder the salvage of motility issues. Well looking at this photograph here of a simple manama tree uh patient. We look at the D. C. I. Again as the district contraction amplitude of the length times the amplitude times the duration the D. L. As the time it takes to go from the forensic contraction to the deceleration point of the wave which is usually about three centimeters above the L. E. S. And more importantly the I. R. P. Integrated relaxation pressures, which generally is 15 millimeters of mercury or less. In addition we have breaks in the parasol tick wave and we measure that when looking at the D. C. I. It falls into several contraction patterns, failed contractions here or when the D. C. Is less than 100 millimeters of mercury over seconds over centimeters. Week is usually between 104 100. Again here's the lower esophageal sphincter Hyper contract. I'll is when the D. C. is over 8000. A premature contraction occurs when the D. L. is less than 4.5 seconds. A failed contraction as you can see is basically no contraction wave at all. Um And the fragmented is when you see these breaks within the peristalsis. When looking at the Chicago classification, I'm going to be dissecting this group in here to evaluate how to make a diagnosis and looking at the I. R. P. Created in the upper limits of normal which we consider about 15 millimeters of mercury which is not a strict yes or no above or below but a general look at it. And if you look at 100% failed peristalsis, we get into three types of a kel asia type 12 and three. Type one is no contract illit E type two is pan pressurization and type three is fastened with the D. L. Tends to be less and the D. C. I. Tends to be elevated. And here's some simple pictures. Classical asia. Here's the lower esophageal sphincter, it does not relax. Here's the US with the contraction and you can see there's no peristalsis at all. Here is pan pressurization of the esophagus again with an elevated or non relaxing L. E. S. And here's a spastic contraction again where low or shortened dl in addition to hyper contractor wave. Another way of looking at a kel asia is using the impedance portion of the high resolution manama tree probe. You can see excess fluid here above the L. E. S. And normally after a swallow. You do not see any retention of fluid. This is similar to a Gi series in which you see a barium swallow where there's a retention of fluid in the upright position. The flip technology as I mentioned is looking specifically at the E. T junction, both at the distance ability index, which is a change of volume overpressure and a diameter or cross sectional area. And this is helpful to really decide prior to the surgery whether it's allowed my ah to me or a heller or in fact a poems to see what the pre and then posed up evaluations are looking at upper limits of normal with an elevated I. R. P. But if it's not type 12 or three, we get into something called the outflow obstructions. And this basically is more of a newer aspect of the Chicago classification in the sense that the differential has been expanded after lots of manama tree have been performed on various patients. Subtypes, the structural causes or secondary causes of an elevated IR pE can bring a can be a ring a web of Oculus post surgical issues come up such as the laproscopic band or nissen infiltrated disorders. One can see malignancies and various medications such as opiates or anti psychotics. When looking at the I. R. P. You have to be careful about the over under diagnosis of this condition. And I'm just going to briefly look at the man a metric pictures of these when typical in a collision. You have contractions of the longitudinal muscle. So you're going to have a foreshortened of the esophagus and the I. R. P. May actually look normal when in fact it isn't. And here you can see that this is diaphragmatic contraction above that is the L. A. S. And lo and behold you have contractions of the esophagus so that you have what looks like a class or type three A kel asia but in fact it is. But the I. R. P. Is noted to be normal. So you really need to look at the tracing to decide whether their pseudo relaxation or not. When looking also at the I. R. P. You can see here there's a Perenchio swallow and the L. E. S. Does not relax. And this can be seen in various conditions as as it can be seen in normal spastic conditions when looking at opiate effect. This is the patient was on opiates with an elevated I. R. P. And after the opiate was reduced or discontinued, you have a normal L. E. S. And here is another picture of a type three uh I. R. P. Issue in which the carassava Jill hernia creates increased pressures which impedes the flow of fluid out of the esophagus. In addition you can have contract I'll disorders with the T junction outflow issues. Looking at the Chicago classifications within normal irp you can then look at either a shortened dl or a high D. C. And in fact this brings us to the Jack cameras ah Fergus as I mentioned with an elevated D. C. Or diffuse esophageal spasm with numerous premature contractions. And here's a picture of the D. L. Is 3.4 seconds. You have a simultaneous contraction and this can be consistent with spasm of the esophagus here. The D. C. I. Is essentially normal note here there's a difference between A D. E. S. And jackhammer based on D. L. And D. C. Here. The D. C. Should be here. The D. L. Is foreshortened and therefore one who thinks of spasm of the esophagus here the D. C. Is elevated and there's no four shortening of the D. L. And both of them can look as though they may have a corkscrew esophagus. So when you get a radio lot graphic interpretation of this you have to remember that manama tree will help sort those two out. Finally we have these other issues of the Chicago classifications which basically reflect ineffective motility disorders. Case one 45 year old male presents with Dysplasia for solids and liquids and endoscopy was a remarkable high resolution geometry is performed. What type of vehicle? Easy does this patient have and what's the best treatment? And again we look at the L. E. S. The I. R. P. The D. L. And whether this pant pressurization or not. Well the answer is B. High resolution manama tree shows that there's type two A kel asia and that there's pan pressurization. Type one as we mentioned. Usually the dilated esophagus without peristaltic function. And type three tends to be spastic which the D. C. I. May be elevated and type two generally is treated with either allowed. My autumn E. Or poems. There are other options we can do. But the answer for this question is B. There are many factors associated with Michael asia outcomes or recently in clinical gastro happens. You can see They looked at 75 studies, 34 different factors. And the bottom line is that there are higher rates of failure with either Uh pneumatic dilatation or my ah to me if the patient was less than 40 years of old of age rather Type two suggested a better prognosis. Mhm. And type three it should be in dilated esophagus with a poor outflow or poor outcome case two, A 68 year old male with a history of a fib on eloquence presents with a six month history of dysplasia for liquids and solids and a £10 weight loss. Barium swallow was said to have been un remarkable. Um Except for some reflux PP I was given without improvement and high resolution geometry was performed. As you can see here you have panned pressurization fluid above the lower subjects. Winter some pseudo medical asia in the sense of the I. R. P. Appears to be normal but in fact it isn't repeat. Barium swell revealed narrowing of the gE junction as you can see. So what's the next step is it endoscopy? Is it Botox? Is it Hello My ah To me, is it balloon dilation or phones? Well, the answer is upper endoscopy. The reason is that there is a narrowing of the ge junction. One needs to make sure that you do not have sued awake Malaysia. The treatment of vehicle asia should be first evaluated to rule out pseudo Malaysia and there's a general characteristics as you can see, advanced age tends to suggest so to wake Malaysia, short duration of symptoms, market weight loss. Um types of tumors can be a gastric carcinoma, squamous cell carcinoma of the esophagus, pancreatic cancer etcetera. And the endoscopic findings tend to be non modularity of the area. Case three A 58 year old Obese woman with diabetes presents with Aphasia for liquids and solids. She underwent a lap band. And as a notice on set of these symptoms, high resolution geometry revealed a shortened esophagus and i. r. p. of 17.4 and distal segmental contractions. What's your most likely diagnosis? Well, we can have Type two equal asia. You can have sued a local asia from a lot band. You can have pseudo a collision from a malignancy, you can have diffuse esophageal spasm or you gonna have GERD. Well, the answer is pseudo ecology related to a lot band. The high resolution geometry revealed an elevated I. AARP which means that this functional obstruction of the ge junction and the differential is large. In this case the patient had a lot Band D. E. S. And GERD revealed normal I. Arps and it's a patient had an elevated irp and type two uh Malaysia revealed pant pressurization and not segmental case four. A 58 year old woman was evaluated for a typical non cardiac chest pains. After an angiogram was normal, she complained of regurgitation and intermittent dysplasia. Pp therapy was not helpful. Manama tree was performed in the 24 hour ph impedance test was normal. And if we look here we look first at the I. R. P. It's normal. We look at the D. C. It's above 8000 and we see that the flow of sailing is directly into the stomach and that there's no incomplete swallowing in the sense of fluid behind the wave. So high resolution manama tree didn't perform a scleroderma. Be diffuse esophageal spasm, see hiatus. Hernia. D. Non relaxing L. E. S. Or eating nutcracker esophagus. Or eat nutcracker esophagus. As noted this tracing peristalsis was maintained in the amplitude of contraction was above 8000. Usually one would say that it was above 5000 to 8000. The Nutcracker and above 8000. Jack camera. But that's semantics. Um scleroderma reveals a low L. E. S. And low amplitudes. D. E. S. Shows intermittent peristalsis with a normal uh with a deal that shortened and a hiatus. Hernia is not seen on this clinical follow up. She sought a second opinion and underwent poems for her atypical chest pain by an experienced gastroenterologist. Unfortunately the patient similar symptoms of regurgitation dysplasia and reflux symptoms. She was placed on a. P. P. Which doesn't really help much and high resolution was repeated and as you can see pre poem, she had an elevated D. C. Post poems, there's no longer any contraction wave. So poems surgically did correct the problem. However there was no wave here and there was a retention of fluid. The L. E. S. Uh was low to begin with and there was normal I. R. P. However the patient now has significant reflux disease case five. The main indication why a 33 year old man with Dysplasia would undergo Sasha geometry when an endoscopy of barium swallow is normal is a symptoms of globes with a foreign sensation. B evaluation for eosinophilic esophagitis, evaluation of heartburn, evaluation, nausea, vomiting or E to evaluate the lower esophageal sphincter pressure. E. To evaluate the globe is as we know the sensation of a foreign body in the back of the throat manama. She really is not very helpful for that. E. O. E. Is a pathologic diagnosis on biopsy and not a man. A metric diagnosis and similar GERD is not a man. A metric diagnosis, bravo capsule or 24 hour ph probe helps to discern whether a patient has abnormal acid reflux or even non acid reflux. The high resolution geometry with impedance can accurately measure the L. E. S pressures and I. R. P. K. Six A middle aged woman presents with dysplasia for liquids and solids and atypical chest pain. Barium swallow was requested. As you can see this is kind of a classic barium swallow. And so the question is what's the differential And what's the answer if there is one. Well could include nutcracker, jackhammer, a kel asia or spasm and high resolution Mahanama tree was performed. And again you have to be careful not to be fooled by the radiologist because they have a certain clinical diagnosis. May or radiographic diagnosis when in fact it may not be the high resolution geometry one and even then it may not be up. So here's high resolution geometry. We look at the I. R. P. E. I. R. P. Is elevated. We look at the L. S. That's elevated. You look at the D. L. Is it shortened or not? Yes. And is there peristalsis? No. So right off the bat we can get rid of nutcracker and Jackhammer because those have normal deals and elevated um tcs spasm and a kel asia certainly can have elevated I. Arps and uh shortened deals. So the answer really would be either C. And D. The I. Ps. Elevated the differentials. I said it couldn't make a leisure or outflow obstructions and the DLS were shortened and his eyes a peristaltic contractions. Sometimes it's difficult to make a diagnosis between a spastic esophagus and type three A kel asia. In fact, there's been studies to show that even among the saf Ecologist there is differentiation between which of the diagnosis can be made K. Six a 68 year old male presents with atypical chest pain which is usual story, cardiac worker was negative, high resolution geometry was performed and as you can see the I. R. P. Is elevated. The lease is normal. We continue and we look at a further report here. The D. C. Is very elevated. Okay. And so now we continue on in Chicago classifications. You can have some pan pressurization, some premature contractions uh and therefore you're kind of left with one or two diagnosis is here is the man a metric findings. Here's the el es the I. R. P. In a very high dc. So does it reveal Jackhammer Malaysia type to Malaysia three or D. E. S. And the reason I say it's strictly because technically to could probably fit in there. It's not going to reveal jack camera or nutcracker because of the normal peristalsis that's not seen. And the elevated D. C. Uh Malaysia type to his pant pressurization. Type three is a spastic Akhil asia type forest spasm of the esophagus with a shortened dl. Well the answer as I mentioned either D. S. Or a type three and that is somewhat debatable. Hopefully you won't have this specific question on because The question I would end up saying is as more of a type three non relaxing L. E. S. The D. C. I. Is elevated Dl. Is shortened and so therefore it would be classified as a spastic esophagus. However, You can also think that it's a segmental pressurization suggesting of type three. So I would end up saying that is type three equal asia some would say it's spasm spasm I'd like to see occasional peristaltic waves and in this case it wasn't what would be the most effective treatment for this. Trial of PPS with H. Two blocker. Trial of nitrates. Trial of calcium blockers. My Autumn era poems or an SSR or SnR answer a lot of telescopic my ah to me you have obstruction or functional obstruction of the G junction so you need to do something about that. You can use different medications to decrease the lower salvages sphincter relaxation. Although it's short term whether it be calcium blockers, nitrates or Botox. And my artemis whether it's through poems or laproscopic will decrease the pressures and therefore help that functional obstruction. It may not um allow for normal peristalsis. So the question comes up. If you do a poems or my Autumn E. Will peristalsis return and the answer is almost never case. Seven. A 45 year old male presents with the long history of Reynaud syndrome and return. Heartburn. Uh endoscopy reveals a mile of the esophagitis. And here is the um high resolution geometry. Let's look here first question L. E. S. And I. R. P. It's slow dc. Low D. L. And you really can't tell because of minimal contractions. These findings on manama Tree would be consistent with either a ca Lesia for china's earlier and stage reflux spasm of the esophagus or not proactively esophagus. The answers and stage reflux. There's a very low lower esophageal sphincter pressure. It can be seen in scleroderma but scleroderma was not one of the answers that was listed. Um secondary a hiatus hernia is present. However it's a very small one since the differentiation between the diaphragmatic contractions and the L. E. S. Is only about a centimeter or two in D. E. S. There's some simultaneous contractions with the background of internet intermittent normal peristalsis and normal elia's question eight Or a case eight. A 68 year old man presents with recurrent regurgitation and a cough. PP. therapy decreases symptoms by 50%. He denies dysplasia. And endoscopy reveals uh normal mucosa and a bravo test is abnormal. Normal is 5% or less high resolution geometry, swallow contraction way of D. C. Here is the L. E. S. And here's diaphragmatic contractions. As you can see the contractions occur here when the patient he's inhaling, take a deep breath. And while you're taking a deep breath as contractions and there's a space here and that's the question of what is this here? And the answer is a large height attorney. Okay so if you see a tracing like this it's a hernia and the question really is what is it? And is there a question or specific uh reason what to do or what we can do about this. The last case today is a 19 year old woman. I saw my office who presented with a six month history of postprandial regurgitation despite PP. I. Therapy. An endoscopy was done by another physician that was normal ph manama tree was performed as was a 24 hour ph pro and you can see here The gastric ph at the beginning was for 2.4, which means that the patient was off the PP. The patient had normal upright Reflex Parameters. 4.8% normal is up to 6.3%. There was no reflux in a recumbent position. That the Meister score was 7.7 Interesting. Nearly all the upright reflux events occurred within 10:15 minutes after the patient. Eight. And in fact when one looks at the number of Reflux episodes, there was an elevated number of Reflux episodes, 87 normal's up to 73. Almost all of them were in the upright position and almost all of them reach the proximal sense the proximal sensor in the proximal esophagus. Here we look at it, patient eats and right after eating you can see the L. E. S. Should be the ph the lower probe is Dowd or acidic and the number of episodes of reflux. And if you actually look at one specific one you can see the ph was about seven, drops down to about two or three and his retrograde reflux coming up. The patient hits the button of regurgitation and down. And in fact the patient was very specific as to when the regurgitation occurred and it was an excellent correlation between our regurgitation and acid reflux coming up. And in fact when you do impede in studies, you can see that there was actually diaphragmatic contraction. This is where the leases regurgitation of fluid coming up and then a clearing wave coming back down and likewise the same thing. This is a representative sample of diaphragmatic contraction fluid coming up and then cleared by a wave. So now the diagnosis becomes clearer as to what's going on in this patient. And the answer is a rumination syndrome. The treatment for rumination syndrome is diaphragmatic breathing techniques, relaxation techniques, and also One can consider the addition of Baffin 10 mg three times a day prior to eating to help decrease transient relaxation of the lower salvageable sphincter. So in all, I gave a brief review of the Chicago classifications. Some questions preferable to the Chicago classifications and if in doubt with any questions regarding high resolution geometry, just go back to the Chicago classification and that should help sort things out. Thank you