Successfully reported this slideshow.
Your SlideShare is downloading. ×

Normal & abnormal swallows in chicago classification version 3.0

Ad
Ad
Ad
Ad
Ad
Ad
Ad
Ad
Ad
Ad

Check these out next

1 of 58 Ad
Advertisement

More Related Content

Slideshows for you (20)

Advertisement

Similar to Normal & abnormal swallows in chicago classification version 3.0 (20)

Advertisement

Normal & abnormal swallows in chicago classification version 3.0

  1. 1. Normal and abnormal swallows in Chicago classification version 3.0 Samir Haffar M.D.
  2. 2. (1) Technical aspects of HRM (2) Metrics of esophagogastric junction (3) Metrics of esophageal contraction (4) Steps to analyze wet swallows Normal & abnormal swallows in esophageal HRM Chicago classification version 3.0
  3. 3. (1) Technical aspects of esophageal HRM
  4. 4. Technical aspects of esophageal HRM 2 phases • Analysis during rest: Recording for several minutes in supine position Allow accommodation to catheter & sensors in SSC to warm Patient swallow as infrequently as possible & breathe quietly Markers of UES, upper & lower border of LES & stomach placed • Analysis during swallow: Administering ten 5 mL water swallows separated by 30 sec This should be considered to be the minimum Bredenoord AJ & Hebbard GS. Neurogastroenterol Motil 2012; 24(Suppl. 1), 5–10.
  5. 5. Esophageal HRM at rest EGJ: esophagogastric junction – LES: lower esophageal sphincter – CD: crural diaphragm Conklin J et al. ACG Annual Postgraduate Course - October 12-13, 2013 Intra-eophageal pressures decrease in inspiration & increase in expiration EGJ (LES & CD) in same location (absence of hiatal hernia) EGJ moves toward stomach & increases in inspiration EGJ moves toward thorax and decreases in expiration
  6. 6. HRM atlas – Medical measurement Systems Esophageal HRM following a wet swallow esophageal pressure topography
  7. 7. Esophageal HRM following a wet swallow Clause's segments Conklin JL. J Neurogastroenterol Motil 2013; 19(3):281-294. 5 ml wet swallow S1: striated esophageal muscles Transition zone: pressure between S1 & S2 S2 & S3: proximal & distal smooth muscles S4: LES repositioning at its resting position
  8. 8. Markers for UES, upper & lower borders of LES & stomach are placed Landmarks of esophageal HRM
  9. 9. 200 mmHg150 mmHg100 mmHg Conklin J, Soffer E, & Pimentel M. Color atlas of high resolution manometry, Springer, 2009. Changing amplification of HRM system As with standard manometry systems, amplification can be changed It is prudent to begin at a standard range (150 mmHg) Gain can then be changed to show variations in pressures
  10. 10. 20 mmHg 40 mmHg 100 mmHg Conklin J, Soffer E, & Pimentel M. Color atlas of high resolution manometry, Springer, 2009. Changing isobaric contour lines (ICL) The pressure is higher inside the contour line and lower outside
  11. 11. Chicago classification version 3.0 no previous foregut surgery Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174. • Individual scoring of at least ten 5-ml swallows in supine position • Esophagogastric junction EGJ morphology at rest EGJ tone at rest Integrated relaxation pressure after WS • Esophageal contraction Contraction vigor Contraction pattern Intra-bolus pressure pattern (pressurization) • Absent in CC v3.0 Contractile front velocity (CFV) Small break (2 – 5 cm) No more nutcracker
  12. 12. (2) Metrics of esophagogastric junction
  13. 13. Metrics of esophagogastric junction • At rest Esophagogastric junction morphology Esophagogastric tone • After wet swallow Integrated relaxation pressure (IRP)
  14. 14. EGJ morphology two main components: LES & crural diaphragm (CD) RIP: respiration inversion point Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174. • Type I EGJ Complete overlap between LES & CD normal Single peak on spatial pressure variation plot • Type II EGJ Slight separation between LES & CD (1-2 cm) Double-peaked on spatial pressure plot Nadir pressure between peaks > intra-gastric pressure • Type III EGJ LES and CD clearly separated (≥ 2 cm) hiatal hernia Nadir pressure between peak < intra-gastric pressure RIP proximal to CD (IIIa) & proximal to LES (IIIb)
  15. 15. Esophagogastric junction type I normal Complete overlap between LES and CD Single peak on spatial pressure variation plot Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
  16. 16. Esophagogastric junction type II Minimal but discernible LES-CD separation (1 – 2 cm) Double-peaked on spatial pressure variation plot Nadir pressure between peaks > intra-gastric pressure Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
  17. 17. Esophagogastric junction type III hiatal hernia Type IIIbType IIIa LES and CD clearly separated (≥ 2 cm) Nadir pressure between peak ≤ intra-gastric pressure RIP proximal at level CD in type IIIa & at level of LES in type IIIb Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
  18. 18. LES-CD separation Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174. Measurement Single peak: LES-CD separation is 0 Double peak: LES-CD separation = distance between peaks Hiatal hernia Type I: absence of hiatal hernia Type II: absence of data on the subject Type III: persistent hiatal hernia LES-CD separation may fluctuate in course of prolonged HRM study Report subtype & range of LES-CD separation throughout the study
  19. 19. Integrated relaxation pressure (IRP) • Mean of the 4 sec of maximal deglutitive relaxation in the10-s window beginning at UES relaxation in reference to gastric pressure • Contributing times can be contiguous or non-contiguous e.g., interrupted by diaphragmatic contraction Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
  20. 20. Carlson DA & Pandolfino JE. Gastroenterol Clin North Am 2013; 42(1): 1–15. Normal integrated relaxation pressure (IRP) 4 nonconsecutive sec of lowest axial pressure displayed by dashed boxes IRP: 4.8 mmHg - Nadir LES pressure: 0.3 mmHg above gastric pressure
  21. 21. Integrated relaxation pressure (IRP) Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174. • Utilizing median rather than mean minimize the impact of one or more outlier values that might skew the result (e.g., due to cough) • Cutoff value for ULN is technology-specific Ranges from 15 (Sierra design) to 28 mmHg (Unisensor design) Only rigorously analyzed for Sierra design Peril of being overly rigid in application of cutoff values
  22. 22. (3) Metrics of esophageal peristalsis
  23. 23. Metrics of esophageal peristalsis • Contraction vigor • Contraction pattern • Intra-bolus pressure pattern (pressurization)
  24. 24. Contraction vigor based on distal contractile integral (DCI) Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174. • Normal contraction DCI > 450 but < 8000 mmHg.s.cm • Failed contraction DCI < 100 mmHg.s.cm • Weak contraction DCI > 100 but < 450 mmHg.s.cm • Ineffective contraction Failed or weak contraction • Hypercontractile DCI ≥ 8000 mmHg.s.cm
  25. 25. Distal contractile integral (DCI) normal value: 450 - 8000 mmHg.s.cm Amplitude x duration x length (mmHg.s.cm) of distal esophageal contraction exceeding 20 mmHg from transition zone to proximal margin of LES (contractile segments 2 & 3) Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
  26. 26. Normal distal contractile integral (DCI) Box from transition zone to proximal aspect of EGJ (yellow dashed line) The 20 mmHg isobaric contour line is determined (black line) Calculated by summing pressures from all time/length foci within field Conklin JL. J Neurogastroenterol Motil 2013; 19(3):281-294.
  27. 27. Failed contraction DCI < 100 mmHg.s.cm Roman S et al. Gastrointest Endosc Clin N Am 2014; 24(4): 545–561.
  28. 28. Weak contraction DCI 100 - 450 mmHg.s.cm Roman S et al. Gastrointest Endosc Clin N Am 2014; 24(4): 545–561.
  29. 29. Hypercontraction DCI > 8 000 mmHg.s.cm Roman S et al. Gastrointest Endosc Clin N Am 2014; 24(4): 545–561.
  30. 30. Hypercontraction occasionally uniquely affects LES & not distal esophagus Normal esophageal contraction followed by prominent LES contraction Including EGJ in DCI measurement (white dashed box) results in dg of hypercontractility Roman S et al. Gastrointest Endosc Clin N Am 2014; 24(4): 545–561.
  31. 31. Contraction pattern • Premature contraction Distal latency < 4.5 sec • Fragmented contraction Large break (> 5 cm length) with DCI > 450 mmHg.s.cm • Intact contraction Not achieving the above criteria
  32. 32. Premature contraction based on distal latency (DL) < 4.5 sec Distal latency is the interval between UES relaxation and contractile deceleration point (CDP) Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
  33. 33. Contractile deceleration point (CDP) key landmark in assessment of contraction pattern Inflexion point along 30 mmHg isobaric contour at which propagation velocity slows, demarcating peristalsis from ampullary emptying Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
  34. 34. Contractile deceleration point (CDP) Isobaric contour line (ICL) set at 30 mmHg 2 troughs of peristaltic esophageal contraction: proximal (P) & distal (D) CDP represents inflexion point in contractile front propagation CDP localized by fitting 2 tangential lines to initial & terminal portions Pandolfino JE et al. Neurogastroenterol Motil 2010; 22:395–e90.
  35. 35. Normal distal latency (DL) normal > 4.5 sec Interval between UES relaxation & contractile deceleration point (CDP) Roman S et al. Gastroenterol Clin North Am 2011; 40(4): 823-835.
  36. 36. CDP in weak contraction & hypercontraction Weak contraction Hypercontraction Pandolfino JE et al. Neurogastroenterol Motil 2010; 22:395–e90. Isobaric contour line at 20 mmHg Isobaric contour line at 50 mmHg
  37. 37. Contractile deceleration point (CDP) Sometimes difficult to localize Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174. • Atypical peristaltic architecture Must be localized within 3 cm of proximal margin of LES • Compartmentalized pressurization Should be localized with the 50 rather than 30 mmHg ICL
  38. 38. CDP must be localized to within 3 cm of proximal margin of LES (between 2 red dotted lines) & prevents miscategorization Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174. Localization of CDP / Atypical peristaltic architecture 2 points can sometimes be identified
  39. 39. Localization of CDP / Pressurization Distal compartmentalized pressurization 2 isobaric contours line (ICL) at 30 & 50 mmHg The 30- and 50-mmHg ICL are not parallel CDP & DL measured at 50-mmHg to exclude area of pressurization Roman S & Kahrilas PJ. Gastroenterol Clin North Am 2011; 40(4): 823-835.
  40. 40. Premature contraction DL < 4.5 cm Roman S et al. Gastrointest Endosc Clin N Am. 2014; 24(4): 545–561.
  41. 41. Contractile front velocity (CFV) normal value < 9 cm/sec Slope of the tangent approximating the 30 mm Hg isobaric contour from the transition zone to the CDP
  42. 42. Normal contractile front velocity (CFV) normal < 9 cm/ sec Kahrilas PJ et al. J Clin Gastroenterol 2008 ; 42(5): 627-635.
  43. 43. Rapid contraction CFV > 9 cm/s Unknown clinical relevance of rapid contraction & normal DL Lack of specificity to define esophageal spasm Removed from Chicago classification v3.0 Roman S & Mion F. HRM: analyse des données et classification de Chicago. Lyon, France
  44. 44. Premature & rapid contraction DL < 4.5 cm & CFV > 9 cm/s Roman S et al. Gastrointest Endosc Clin N Am. 2014; 24(4): 545–561.
  45. 45. Fragmented contraction Large break (> 5 cm length) in the 20-mmHg ICL with DCI > 450 mmHg.s.cm Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174.
  46. 46. Fragmented contraction large break > 5 cm & DCI > 450 mmHg.s.cm Only break > 5 cm in length considered abnormal in Chicago classification version 3.0 Roman S et al. Gastrointest Endosc Clin N Am. 2014; 24(4): 545–561.
  47. 47. Small breaks (2-5 cm) Small breaks considered normal in Chicago classification version 3.0 Roman S & Mion F. HRM: analyse des données et classification de Chicago. Lyon, France
  48. 48. Intra-bolus pressure pattern (pressurization) determine pressurization with isobaric contour at 30 mmHg Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174. • Pan-esophageal pressurization Uniform pressurization >30 mmHg from UES to EGJ • Compartmentalized pressurization Pressurization >30 mmHg from contractile front to EGJ • EGJ pressurization Pressurization between LES & CD with LES-CD separation • Normal pressurization No bolus pressurization > 30 mmHg
  49. 49. Panesophageal pressurization extending from UES to EGJ Hirano I. ACG Regional Postgraduate Course - St. Louis, MO - 2013
  50. 50. Compartmentalized pressurization distal esophageal pressurization from contractile front to EGJ Hirano I. ACG Regional Postgraduate Course - St. Louis, MO - 2013
  51. 51. Esophagogastric junction pressurization Pressurization between LES & CD in conjunction with hiatal hernia Pandolfino J & Roman s. Thorac Surg Clin 2011; 21(4): 465–475.
  52. 52. ContractionPressurization Pressurization or contraction? Using spatial pressure variation plot on right of each EPT plots Each spatial pressure variation plot identified by white dashed line Pressurization: intraesophageal pressure not vary between UES & EGJ Esophageal contraction: pressure variations along esophageal body Roman S & Kahrilas PJ. Gastroenterol Clin North Am 2013; 42(1): 27–43.
  53. 53. (4) Steps to analyze wet swallows
  54. 54. Stepwise EPT analysis of individual swallows Carlson DA et al. Gastroenterol & hepatol 2015; 11(6):374-384.
  55. 55. Contraction pattern Kahrilas PJ et al. Neurogastroenterol Motil 2015; 27:160-174. • Failed contraction DCI < 100 mmHg·cm·sec or DCI < 450 mmHg.s.cm + DL < 4.5 sec • Weak contraction DCI 100 - 450 mmHg.s.cm • Ineffective contraction Failed or weak contraction • Hyper-contraction DCI > 8 000 mmHg.s.cm • Premature contraction DL < 4.5 cm • Rapid contraction CFV > 9 cm/sec - removed from CC v3.0 • Fragmented contraction Peristaltic break > 5 cm + DCI > 450 • Normal contraction Not achieving any of the above criteria
  56. 56. Failed contraction (weak & premature) DCI 100 - 450 mmHg.s.cm + DL < 4.5 sec Roman S et al. Gastrointest Endosc Clin N Am. 2014; 24(4): 545–561.
  57. 57. Metrics of a normal wet swallow Roman S et al. Gastrointest Endosc Clin N Am. 2014; 24(4): 545–561. EGJ morphology type I Normal EGJ tone IRP: 0.8 (nl < 15 mmHg) DCI: 1107 (nl: 450-8000 mmHg.s.cm) DL: 7.2 (nl > 4.5 s) Absence of large break Absence of pressurization
  58. 58. Thank You

×