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What is new in GERD investigation?

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  • Intragastric pH Monitoring:The evidence supporting the clinical significance and applicability of gastric pH monitoring is insufficient to recommend its routine use inclinical practice.Proximal pH Recording:available evidence does not support the routine use of proximal pH monitoring in clinical practice.
  • Therefore, pH recordings using the wireless pH system improve patients’ ability to perform their daily activities and thus provide a more accurate picture of their acid exposure profile as well as improve their compliance with the study.
  • Using the wireless pH system, the 95th percentile for distal esophageal acid exposure for control subjects was 5.3%, a value higher than values reported in several although not all catheter-based system studies. The higher acid exposure threshold reported in healthy controls using the wireless pH system may be the consequence of less restriction in daily activities or the result of a thermal calibration error that existed in the pH catheter systems.The 48-h data could be interpreted using an average of the 2 days or only the 24-h period with the greatest acid exposure (worst day analysis). A significant increase in the sensitivity of pH testing and small decrease in specificity were evident when utilizingthe worst day data compared with either the initial 24-h or overall 48-h data in comparing controls with GERD patients.
  • Strong correlation in esophageal acid exposure between 2 systemsCFS under recorded acid exposure
  • Relatively new technique developed in early 1990s at Helmholtz Institute in Aachen (Germany)Silny* provided first description of this technique that assesses intraluminal bolus movement by measuring changes in conductivity of intraluminal content
  • A recent, multicenter study examined the impedance characteristics of 60 healthy subjects during 24-h ambulatory monitoring. Based on impedance values 5 cm above the LES, the median number of total reflux episodes per 24 h was 30, the majority of which occurred in the upright position.Approximately two-thirds of the episodes were acid and another third weakly acidic reflux. Weakly alkaline reflux was distinctly uncommon in this healthy cohort. Similar frequencies were recently reported from a multicenter European study. References:Shay S, Tutuian R, Sifrim D, et al. Twenty-four hour ambulatory simultaneous impedance and pH monitoring: A multicenter report of normal values from 60 healthy volunteers. Am J Gastroenterol 2004;99:1037–43.Zerbib F, Bruley des Barannes S, Roman S, et al. 24 hour ambulatory esophageal multichannel intraluminal impedance-pH in healthy European subjects. Gastroenterology 2005;128:A396.
  • In the esophagus, this enables simultaneous recording from all segments, including the sphincteric regions, pharynx, and stomach, without the need to reposition the catheter during the study, the so-called pull-through technique.
  • 2 major potential indications for NBI and HRE:1- Detecting specialized intestinametaplasia (SIM) in the short form of the condition 2- More importantly, identifying areas of dysplasia/carcinoma in patients with BO under surveillance
  • As neoplastic foci in the oesophagus may not be recognisable at endoscopy. The recommended surveillance protocol (the so-called Seattle protocol) consists of random four-quadrant biopsies at1–2 cm intervals cm in the absence of morphologically distinct lesions such as plaques, nodules, or ulcers.This protocol, however, is time consuming, costly, and insensitive due to the patchy nature of HGIN and early cancer in BE.Of note, the distribution of SIM in the columnar lined distal oesophagus has also been shown to be patchy, with a yield for standard biopsy of 80% for long-segment BO (> 3 cm) and 30% for short segment BO (< 3 cm).An ideal technique would be one that could detect the maximum number of cases of metaplasia and dysplasia with the minimum (or none) number of biopsy specimens.
  • Magnifying electronic endoscope used was a GIF-Q240ZAuthors used for the first time the combination of a mucosal surface and capillary pattern. Maximum magnification ratio, X 80; Olympus Medical Systems Co, Tokyo, Japan
  • Magnifying electronic endoscope used was a GIF-Q240ZMaximum magnification ratio, X 80; Olympus Medical Systems Co, Tokyo, JapanAuthors used for the first time the combination of a mucosal surface and capillary pattern.
  • Magnifying electronic endoscope used was a GIF-Q240ZMaximum magnification ratio, X 80; Olympus Medical Systems Co, Tokyo, JapanAuthors used for the first time the combination of a mucosal surface and capillary pattern.
  • Magnifying electronic endoscope used was a GIF-Q240ZMaximum magnification ratio, X 80; Olympus Medical Systems Co, Tokyo, JapanAuthors used for the first time the combination of a mucosal surface and capillary pattern.
  • Magnifying electronic endoscope used was a GIF-Q240ZMaximum magnification ratio, X 80; Olympus Medical Systems Co, Tokyo, JapanAuthors used for the first time the combination of a mucosal surface and capillary pattern.
  • Magnifying electronic endoscope used was a GIF-Q240ZMaximum magnification ratio, X 80; Olympus Medical Systems Co, Tokyo, Japan.Authors used for the first time the combination of a mucosal surface and capillary pattern. Combining the narrow band imaging system and a magnifying endoscope allows simple and clear visualization of micropatterns of the superficial mucosal layer, its fine mucosal pattern and its capillary pattern, simply by switching the lighting system, without the need for dye or acetic acid.
  • Vinelike: تشبة الكرمةMagnifying electronic endoscope used was a GIF-Q240ZMaximum magnification ratio, X 80; Olympus Medical Systems Co, Tokyo, JapanAuthors used for the first time the combination of a mucosal surface and capillary pattern. Combining the narrow band imaging system and a magnifying endoscope allows simple and clear visualization of micropatterns of the superficial mucosal layer, its fine mucosal pattern and its capillary pattern, simply by switching the lighting system, without the need for dye or acetic acid.
  • Coiled: سلسلة أنابيبMagnifying electronic endoscope used was a GIF-Q240ZMaximum magnification ratio, X 80; Olympus Medical Systems Co, Tokyo, JapanAuthors used for the first time the combination of a mucosal surface and capillary pattern. Combining the narrow band imaging system and a magnifying endoscope allows simple and clear visualization of micropatterns of the superficial mucosal layer, its fine mucosal pattern and its capillary pattern, simply by switching the lighting system, without the need for dye or acetic acid.
  • Magnifying electronic endoscope used was a GIF-Q240ZMaximum magnification ratio, X 80; Olympus Medical Systems Co, Tokyo, JapanAuthors used for the first time the combination of a mucosal surface and capillary pattern. Combining the narrow band imaging system and a magnifying endoscope allows simple and clear visualization of micropatterns of the superficial mucosal layer, its fine mucosal pattern and its capillary pattern, simply by switching the lighting system, without the need for dye or acetic acid.
  • Magnifying electronic endoscope used was a GIF-Q240ZMaximum magnification ratio, X 80; Olympus Medical Systems Co, Tokyo, JapanAuthors used for the first time the combination of a mucosal surface and capillary pattern. Combining the narrow band imaging system and a magnifying endoscope allows simple and clear visualization of micropatterns of the superficial mucosal layer, its fine mucosal pattern and its capillary pattern, simply by switching the lighting system, without the need for dye or acetic acid.
  • Prototype AF endoscopy system used in this study includes a high resolution videoendoscope and an AF imaging (AFI) modality.The high-resolution videoendoscope in this system has two separate monochromatic charge-coupled devices (CCD); one for white-light endoscopy (WLE), and one for AFI. The AF image, therefore, has 3 spectral components: (1) total AF in response to blue light excitation, (2) green reflectance light, and (3) red reflectance light. WLE and AFI can be alternated by means of a switch located conveniently on the endoscope.

Transcript

  • 1. What is new in GERD investigation?Samir Haffar M.D.Assistant Professor of Gastroenterology
  • 2. What is new in GERD investigation? Bravo capsule Combined MII-pH High resolution manometry Imaging techniques in Barrett’s esophagusMII: Multiple Intraluminal Impedance
  • 3.  Bravo capsule
  • 4. Normal 24 hours esophageal pH monitoringComposite DeMeester score: 8.4DeMeester normal < 14.72 (95th percentile)Bremner CG et al. Esophageal disease & testing. Taylor & Francis Group, 2005.
  • 5. Composite scoring systemsJohnson & DeMeester is the most commonly usedPercentage of total time pH < 4Percentage of upright time pH < 4Percentage of supine time pH < 4Number of reflux episodesNumber of reflux episodes >5 minLongest reflux episodeDeMeester scoreNormal < 14,72
  • 6. Normal values of DeMeester’s score50 healthy volunteersDeMeester TR et al. Ann Surg 1976 ; 184 :459 – 470.
  • 7. Symptom association• Symptom index: positive if ≥ 50%• Symptom sensitivity index: positive if  10 %• Symptom association probability calculation: 95%• Integrated aciditySimply giving impression of potential association
  • 8. Limitations of esophageal pH monitoringIs it the gold standard?• Normal 24 hr pH in 25% of patients with erosive esophagitis• Some patients with very convincing histories but negativeendoscopy & normal pH test• Differences in acid exposure documented between 2 pHprobes attached to each other & used simultaneously• Day-to-day variability may be seen with normal pH studyin one day & abnormal in another day
  • 9. Bravo system (Medtronics)Esophageal Probe25 x 6 x 5.5 mmBatterypHelectrodeSuctionchamberRadiotransmitterDelivery systemReceiver100 x 70 x 30 mm - 165 g
  • 10. Advantages of Bravo capsule• Better tolerance by patients• Fixed position of the capsule (6 cm above SCJ*)• Prolonged monitoring under more physiologicconditions (48 hours)* SCJ: squamocolumnar junction
  • 11. Bravo normal values50 asymptomatic volunteers1st 24 h 2nd 24 hMean(+ SD)95thpercentileMean(+ SD)95thpercentile% total time at pH < 4 1.79 (2.16 5.89 1.78 (1.78) 5.64% upright time at pH < 4 2.45 (3.14) 7.81 2.54 (2.57) 7.46% supine time at pH < 4 0.37 (1.18) 1.58 0.34 (1.28) 1.29Number of reflux episodes 21.2 (18.5) 55.30 22.3 (19.8) 56.15No of reflux episodes >5 min 0.62 (1.21) 3.55 0.75 (1.15) 3.00Longest reflux episode 3.79 (4.31) 11.23 5.95 (4.52) 17.03DeMeester score 6.02 (4.82) 15.93 5.95 (4.52) 15.48
  • 12. Conventional pH vs Bravo capsuleHead to head comparison – 40 patientsBruley des Varannes S. Gut 2005 ; 54 ; 1682 – 1686.
  • 13. Bravo capsuleCauses of under-recording• Data drop-up• Short reflux event not recorded• Reflux events appear shorter
  • 14. Bravo capsuleData drop-outMalfunctions in the electronics or the receiverInterpreted as artifact & not represented in final pH reportImproved by 7 cm antenna & use of fiberglassGastrointest Endoscopy Clin N Am 2005 ; 15 : 307 – 318.
  • 15. Bravo capsuleShort reflux events not recordedBruley des Varannes S. Gut 2005 ; 54 ; 1682 – 1686.
  • 16. Bravo capsuleReflux events appear shorterBruley des Varannes S. Gut 2005 ; 54 ; 1682 – 1686.
  • 17. Trouble shooting in Bravo capsule• Severe odynophagia & chest pain (5%)Chest radiography to exclude perforationViscous lidocaineEndoscopic removal if symptoms continue• Capsule detachment• Failure to dislogeEndoscopic removal similar to polypectomy
  • 18. Bravo capsuleClassic early detachment (10% of patients)Easily recognized during inspection of pH tracingGastrointest Endoscopy Clin N Am 2005 ; 15 : 307 – 318.Sudden prolonged drop in pH represents capsule in stomachSharp rise as capsule enters small intestine through pylorus
  • 19. Endoscopic removal of Bravo capsuleGastrointest Endoscopy Clin N Am 2005 ; 15 : 307 – 318.
  • 20.  Combined MII-pH(MII-pH)
  • 21. Principle of “MII”• 2 steel rings separated by isolator• Alternating-current generator to apply electrical PD• Circuit closed through electrical charges (ions)contained in structures surrounding the catheterGastrointest Endoscopy Clin N Am 2005 ; 15 : 257 – 264.
  • 22. Impedance scaleRefluxate: High conductivity & low impedanceAir: Low conductivity & high impedanceBremner CG et al. Esophageal disease & testing.Taylor & Francis Group, New York, 1st edition, 2005.
  • 23. Advantages of MII• Content of refluxate Liquid – Gas – Mixed• Direction of bolus Anterograde – retrograde• Height of refluxate• pH characteristics Acid(combined MII-pH) Weekly acidWeekly alkalineAcid re-reflux
  • 24. Liquid bolusGastrointest Endoscopy Clin N Am 2005 ; 15 : 257 – 264.1) Initial drop Liquid enters impedance-measuring segment2) Rise Bolus cleared from this segment3) Overshoot Decreased luminal cross-section during contraction4) Return to baseline
  • 25. Air bolus(Belch, Air swallow)1) Rapid rise Presence of air bolus inside esophagus2) Rapid decrease Air bolus clears from this segmentGastrointest Endoscopy Clin N Am 2005 ; 15 : 257 - 264.
  • 26. Mixed air – liquid Bolus1) Rapid Rise Air in front of the bolus2) Rapid drop Liquid component of mixed bolus3) Rise Liquid being cleared from this segment4) Return to baselineGastrointest Endoscopy Clin N Am 2005 ; 15 : 257 – 264.
  • 27. Antegrade bolus movement (MII)Observed during swallowingProgression of impedance from proximal to distalGastrointest Endoscopy Clin N Am 2005 ; 15 : 257 – 264.
  • 28. Retrograde bolus movement (MII)Observed in refluxProgression of impedance from distal to proximalGastrointest Endoscopy Clin N Am 2005 ; 15 : 257 – 264.
  • 29. Combined MII• MII used clinically only in combination– With esophageal manometry (MII-EM)– With pH (MII-pH)• MII not considered as replacement for manometry &pH techniques but as complementary procedure thatexpands diagnostic potential of esophageal functiontesting & reflux monitoring
  • 30. Combined MII-pH probe• Impedance orifices3, 5, 7, 9, 15, & 17 cm from the tip• pH orifice5 cm from the tip•  MII-pH probe =  pH probeDo not change patient comfortBremner CG et al. Esophageal disease & testing.Taylor & Francis Group, NY, 1st edition, 2005.
  • 31. “Sleuth” monitor – Sandhill“Sleuth” monitor attached to the catheter& worn around a belt during the recording period
  • 32. GERD classification by combined MII-pH Acid refluxReflux with drop of pH from above 4.0 to below 4.0 Superimposed acid reflux (Acid re-reflux)Acid reflux occurs while pH < 4.0 Weakly acidic refluxReflux results in esophageal pH between 4.0 & 7.0 Weakly alkaline refluxReflux with nadir esophageal pH does not drop < 7.0Sifrim D et al. Gut 2004 ; 53 ; 1024 – 1031.
  • 33. Acid reflux (MII-pH)Gastrointest Endoscopy Clin N Am 2005 ; 15 : 361 – 371.
  • 34. GERD classification by combined MII-pH Acid refluxReflux with drop of pH from above 4.0 to below 4.0 Superimposed acid reflux (Acid re-reflux)Acid reflux occurs while pH < 4.0 Weakly acidic refluxReflux results in esophageal pH between 4.0 & 7.0 Weakly alkaline refluxReflux with nadir esophageal pH does not drop < 7.0Sifrim D et al. Gut 2004 ; 53 ; 1024 – 1031.
  • 35. Superimposed acid reflux (MII-pH)Gastrointest Endoscopy Clin N Am 2005 ; 15 : 361 – 371.
  • 36. GERD classification by combined MII-pH Acid refluxReflux with drop of pH from above 4.0 to below 4.0 Superimposed acid reflux (Acid re-reflux)Acid reflux occurs while pH < 4.0 Weakly acidic refluxReflux results in esophageal pH between 4.0 & 7.0 Weakly alkaline refluxReflux with nadir esophageal pH does not drop < 7.0Sifrim D et al. Gut 2004 ; 53 ; 1024 – 1031.
  • 37. Weakly acidic reflux (MII-pH)Gastrointest Endoscopy Clin N Am 2005 ; 15 : 361 – 371.
  • 38. GERD classification by combined MII-pH Acid refluxReflux with drop of pH from above 4.0 to below 4.0 Superimposed acid reflux (Acid re-reflux)Acid reflux occurs while pH < 4.0 Weakly acidic refluxReflux results in esophageal pH between 4.0 & 7.0 Weakly alkaline refluxReflux with nadir esophageal pH does not drop < 7.0Sifrim D et al. Gut 2004 ; 53 ; 1024 – 1031.
  • 39. Weakly alkaline reflux (MII-pH)Gastrointest Endoscopy Clin N Am 2005 ; 15 : 361 – 371.
  • 40. Recommendations for MII-pH monitoring• Endoscopy-negative patients with heartburn orregurgitation despite PPI & performed on PPI therapy• Utility of impedance in refractory reflux patients withchest pain or extraesophageal symptoms unproven• Current interpretation relies on SI, SSI or SAP• Therapeutic implications of abnormal test unprovenACG Practice Guidelines: Esophageal reflux testing.Am J Gastroenterol 2007 ; 102 : 668 – 685.
  • 41.  High Resolution Manometry(HRM)
  • 42. High-resolution manometry catheter4.2 mm in diameter36 solid-state pressure sensors12 loci in each sensor (arrow)Spaced at 1-cm intervalsRecording segment of 35 cmConklin J, Pimentel M, Soffer E. Color atlas of high resolution manometry.Springer Science & Business Media, NY, USA, 2009.
  • 43. Normal High Resolution ManometrySpatiotemporal plotTime on the x-axisPressure on the y-axisPressure represented by colorCooler color = lower pressureWarmer color = higher pressureUES pressure  esophagus (*)LES pressure  stomach (**)Conklin J, Pimentel M, Soffer E. Color atlas of high resolution manometry.Springer Science & Business Media, NY, USA, 2009.
  • 44. Hiatus hernia in HRM2 zones of high pressure in GEJOne at 41 cm: LES (arrow)One at 49 cm: Diaphragm (*)Conklin J, Pimentel M, Soffer E. Color atlas of high resolution manometry.Springer Science & Business Media, NY, USA, 2009.
  • 45. pH catheter positioningHigh Resolution Manometry Conventional manometryDifficult pH catheter positioning in conventional manometryUp to 4 cm too distal compared to positioning based on HRMFox M R et al. Gut 2008 ; 57 ; 405 – 423.
  • 46. Comparison of different manometric methodsConventional pull-through manometryConventionalSleeve manometryHRMCost Inexpensive Inexpensive ExpensiveFox M R et al. Gut 2008 ; 57 ; 405 – 423.Execution Relatively elaborateTime consumingRelatively elaborateTime consumingRelatively simpleFastInterpretation Requires experience Requires experience Relatively easyLES function& relaxationLimited Yes YesUES function& relaxationNo Limited Yes
  • 47.  Imaging techniques in Barrett’sesophagus
  • 48. Barrett’s esophagusLight white endoscopyContrast between squamous & columnar epitheliumis characteristic of Barrett‟s esophagus
  • 49. NBI Endoscopy in short segment BEImage obtainedby NBI endoscopeHamamoto Y. J Gastroenterol 2004 ; 39 : 14 – 20.Image obtained byconventional endoscope
  • 50. Various imaging techniques in BE• Light endoscopy Magnification endoscopy (ME)Chromoendoscopy (dyes)High-resolution endoscopy (HRE)• Optical endoscopy Narrow band imaging (NBI)Autofluorescence imaging (AFI)Optical coherence tomography• Endomicroscopy EndocytoscopyConfocal microscopy• Optical spectroscopy Fluorescence spectroscopyRaman spectroscopyElastic scattering spectroscopy• Biomarker-based imagingSharma P et al. Gastrointest Endosc 2006 ; 64 : 188 – 92.
  • 51. Which imaging modalities should be used?• In practice, it is routine to use “screening‟‟ test followedby test with ‘‘higher specificity‟‟ to confirm diagnosis• In future, use an approach based on „„coverage‟‟ by:Screening: HRE, NBI & AFIHigh specificity: endocytoscopy & confocal endoscopySharma P et al. Gastrointest Endosc 2006 ; 64 : 188 – 92.
  • 52. Magnification Endoscopy with NBI• Classifications: Mucosal patternCapillary pattern• Different classification in different studiesOne simple accepted classification desirable• Lack of large randomized studies• Assess of intra- & interobserver reproducibilityMessmann H et al. Gastrointest Endosc 2007 ; 65 : 47 – 49.
  • 53. Magnifying endoscopy with NBI in Barrett’sMucosal pattern 1: Round or ovalGoda K et al. Gastrointest Endosc 2007 ; 65 : 36 – 46.
  • 54. Goda K et al. Gastrointest Endosc 2007 ; 65 : 36 – 46.Magnifying endoscopy with NBI in Barrett’sMucosal pattern 2: Long straight
  • 55. Goda K et al. Gastrointest Endosc 2007 ; 65 : 36 – 46.Magnifying endoscopy with NBI in Barrett’sMucosal pattern 3: Villous
  • 56. Goda K et al. Gastrointest Endosc 2007 ; 65 : 36 – 46.Magnifying endoscopy with NBI in Barrett’sMucosal pattern 4: Cerebriform
  • 57. Goda K et al. Gastrointest Endosc 2007 ; 65 : 36 – 46.Magnifying endoscopy with NBI in Barrett’sMucosal pattern 5: Irregular
  • 58. Magnifying endoscopy with NBI in Barrett’sVascular pattern I: Honeycomb-likeGoda K et al. Gastrointest Endosc 2007 ; 65 : 36 – 46.
  • 59. Magnifying endoscopy with NBI in Barrett’sVascular pattern II: VinelikeGoda K et al. Gastrointest Endosc 2007 ; 65 : 36 – 46.
  • 60. Magnifying endoscopy with NBI in Barrett’sVascular pattern III: Coiled or curly hairedGoda K et al. Gastrointest Endosc 2007 ; 65 : 36 – 46.
  • 61. Magnifying endoscopy with NBI in Barrett’sVascular pattern IV: DNA-spiral likeGoda K et al. Gastrointest Endosc 2007 ; 65 : 36 – 46.
  • 62. Magnifying endoscopy with NBI in Barrett’sVascular pattern V: IrregularGoda K et al. Gastrointest Endosc 2007 ; 65 : 36 – 46.
  • 63. Combination of mucosal & vascular pattern58 patients• Barrett’s epitheliumMucosal pattern 4 & capillary pattern IVSignificantly raised possibility of SIM (OR: 4.78 & 51.6)• CarcinomasMucosal pattern 5 & capillary pattern VDetect all carcinomas (100% sensitivity & specificity)SIM: Specialized Intestinal MetaplasiaGoda K et al. Gastrointest Endosc 2007 ; 65 : 36 – 46.
  • 64. Autofluorescence Imaging (AFI)Prototype endoscopy system• Two separate charge-coupled devices (CCD)One for white-light endoscopy (WLE) & one for AFI• AFI Nondysplastic BE appears greenPotentially neoplastic areas appear blue/violet• In a pilot study, AFI detects more dysplastic & neoplasticchanges than conventional endoscopy with biopsiesKara MA et al. Gastrointest Endosc 2005 ; 61 : 679 – 85.
  • 65. Autofluorescence Imaging in BEBarrett‟s esophagusWhite-light endoscopyBlue/purple color: HGD/ECBiopsy of blue/purple area: ECBiopsy of green area: no dysplasiaAutofluorescence ImagingKara MA et al. Gastrointest Endosc 2005 ; 61 : 679 – 85.
  • 66. EndocytoscopyBased on principle of contact light microscopy• 2 prototypes: probe-based & endoscope-based systems• Mucosa treated with mucolytic agent (N-acetylcysteine)• Staining with methylene blue or toluidine blue• Assessment of cytological & architectural features:Size & shape of nuclei – nucleus-to-cytoplasm ratio• Promising technique with potential clinical benefitsbut further studies are neededASGE Technology Committee. Gastrointest Endosc 2009 ; 70 : 610 – 613.
  • 67. Endocytoscopy images in esophagus(1400x)Small rounded regularly arrangednuclei of normal mucosaDensely packed darkly stained& enlarged nuclei of SCCASGE Technology Committee. Gastrointest Endosc 2009 ; 70 : 610 – 613.
  • 68. Use of HRE & NBI with careful examinationof the BE segment for any lesions suspicious forneoplasia appears to be the best practice‘Spend more time lookingand less time biopsying’’Sharma P et al. Gastrointest Endosc 2006 ; 64 : 188 – 92.
  • 69. Thank You