DOTT. NICOLA DE BORTOLI - 1° Giornata Master ECM in Gastroenterologia 2016 (11/11/2016) - Fondazione Santa Lucia - Sala Congressi - Roma Sito: www.asmad.net Canale Youtube: https://youtu.be/ejLwZULp5zE

1. MANOMETRIA ESOFAGEA AD ALTA RISOLUZIONE
Nicola de Bortoli
Assistant Professor of Medicine
Department of Translational Research and New Technologies in Medicine and Surgery
University of Pisa

2. 1. SINTOMI ESOFAGEI:
i. Disfagia, dolore toracico (non-cardiaco)
ii. Sintomi da RGE (tipici e atipici)
2. POSIZIONAMENTO DI DEVICES (pH-metria – pH-impedenziometria):
i. Individuare il margine superiore del LES
ii. Escludere disordini primitivi della motilità
3. PRE-TRATTAMENTO CHIRURGICO ANTIREFLUSSO
DEFINIRE LA FUNZIONE MOTORIA
IDENTIFICARE ANOMALIE DELLA MOTILITA’
STABILIRE UN TRATTAMENTO BASATO SULLA DIAGNOSI FUNZIONALE
Digestive and Liver Disease 2016;48(10)1124-35

3. FUNCTIONAL IMAGING OF ESOPHAGEAL PERISTALSIS
Standard Manometry (ten 5-mL swallows performed in supine position)

4. LES
Courtesy of Dr. Massimo Bellini

5. Normali onde peristaltiche e rilasciamento LES
Courtesy of Dr. Massimo Bellini

6. manometria esofagea:
morfologia delle onde di contrazione
Courtesy of Dr. Massimo Bellini

7. ,
Presenza di 100% onde simultanee
Presenza di >10% onde simultanee
Presenza di onde con ampiezza > 180mmHg (>20%)
Onde con ampiezza media < 25mmHg

8. Functional Imaging of Esophageal Peristalsis
High Resolution Manometry (ten 5-mL swallows performed in supine position)
Clouse Plot

10. EGJ morphology: Type I andType II
TYPE I
Complete overlap
of CD and LES
components with
single peak on the
spatial pressure
variation plot.
Double-peaked pressure
zone with the interpeak
nadir pressure greater
than gastric pressure
(separation of 1–2 cm).
TYPE II

11. PIP
Double-peaked pressure zone with the interpeak nadir pressure less
than or equal to gastric pressure
EGJ morphology Type III = Hiatal Hernia
TYPE III

12. Esophagogastric junction morphology has been shown to be an important determinant of
EGJ barrier function in that spatial separation between LES and CD facilitates
gastroesophageal reflux.
Tolone S, de Bortoli N, et al. Neurogastroenterol Motil 2015
Bredenoord AJ et al. Gastroenterology 2006
EGJ morphology

13. EGJ Relaxation: Integrated Relaxation Pressure (IRP)
Mean of the 4 s of maximal deglutitive relaxation in the 10-s window beginning at UES
relaxation. Contributing times can be contiguous or non-contiguous (e.g., interrupted by
diaphragmatic contractions). Referenced to gastric pressure.
IRP vn < 15 mmHg

14.  The best validated metric of deglutitive relaxation
 Advantages of a sleeve-type recording
 Accounts for both nadir and persistence of relaxation
Ghosh SK et al. Am J Physiol 2007
EGJ Relaxation Measure Achalasia sensitivity False Negative
Single Sensor Nadir (<7 mmHg) 52% 48%
High Resolution Nadir (<10 mmHg) 69% 31%
4s IRP (<15 mmHg) 97% 3%
EGJ Relaxation: Integrated Relaxation Pressure (IRP)

15. 50
40
30
20
10
50
40
30
20
10
Nadir Pressure: 90%
Nadir Pressure: 90%
ARE THOSE RELEASING LES PRESSURE SIMILAR?
mmHg
mmHg
SWALLOW
RILASCIAMENTO CCORDINATO E COMPLETO
RILASCIAMENTO CCORDINATO E INCOMPLETO
IRP= 5mmHg
IRP= 16mmHg

16. EGJ Relaxation: esophageal shortening
Pseudorelaxation
SHORTENING

17. ContractionVigor – Distal Contractile Integral (DCI)
Amplitude*duration*length (mmHg*s*cm) of the distal esophageal contraction exceeding
20 mmHg from the transition zone to the proximal margin of the LES (Clouse, 2nd and 3rd
contractile segments)
5 s
0
5
10
15
20
25
30
35
P (transition zone)
100
50
0
150
mmHg
20LES
UES
Lengthalongtheesophagus(cm)
Time (s)

18. mmHg
SFINTERE ESOFAGEO SUPERIORE
GIUNZIONE
ESOFAGO
GASTRICA (EGJ)
DCI = mmHg-s-cm
Zona di transizione
Punto di
decelerazione
LATENZA DISTALE
RILASCIAMENTO EGJ (IRP)
cm
5 s
DCI values
< 100 ineffective
100-450 weak
450-8000 Normal
> 8000 Hypertensive
DCI values

19. ContractionVigor – Distal Contractile Integral (DCI)
Failed (DCI <100 mmHg*s*cm) Weak (DCI >100 <450 mmHg*s*cm)

20. Hypercontractile (DCI >8000 mmHg*s*cm)
ContractionVigor – Distal Contractile Integral (DCI)

21. PREMATURE CONTRACTION
DL <4.5 s not weak
Contraction Pattern – Distal Latency (DL)

22. The Chicaco Classification V3.0: Hierarchical Analysis

23. Impaired EGJ Relaxation (IRP>15mmHg)
TYPE I ACHALASIA (classic achalasia): elevated median IRP (>15 mmHg*), 100%
failed peristalsis (DCI <100 mmHgscm)
Premature contractions with DCI values less than 450 mmHg*s*cm satisfy criteria for failed peristalsis

24. TYPE II ACHALASIA (with esophageal compression): elevated median IRP (>15
mmHg), 100% failed peristalsis, panesophageal pressurization with ≥20% of
swallows
Contractions may be masked by esophageal pressurization and DCI should not be calculated.
Impaired EGJ Relaxation (IRP>15mmHg)

25. TYPE III ACHALASIA (spastic achalasia): elevated median IRP (>15 mmHg*), no
normal peristalsis, premature contractions with DCI >450 mmHg*s*cm with
≥20% of swallows
May be mixed with panesophageal pressurization.
Impaired EGJ Relaxation (IRP>15mmHg)

26. AchalasiaTreatment Outcome by EPT Subtype
1 Pandolfino JE, et al Gastroenterology 2008
2 Salvador R, et al J Gastrointest Surg 2010
3 Pratap N, et al Neurogastroenterol Mot 2011
4 Rohof W, et al Gastroenterology 2013
Publication Year N Rx Type Type I Type II Type III
Pandolfino1 2008 99 PD, LHM, Botox 56% (21) 96% (49) 29% (29)
Salvador2 2010 246 LHM 85% (96) 95% (127) 69% (23)
Pratap3 2011 51 PD 63% (24) 90% (24) 33% (3)
Rohof4 2013 176 RCT
PD 86%
(44)
100%
(114)
40%
(18)
LHM 81% 95% 86%
Percent with ‘good’ outcome
PD – Pneumatic Dilation; LHM - Laparoscopic Heller myotomy; BoTox - Botulinum Toxin; RCT –
Randomised Clinical Trial.

27. The Chicaco Classification V3.0: Hierarchical Analysis

28. Major disorders of peristalsis
Distal Esophageal Spasm (DES)
Premature Contraction: DL <4.5 s not weak
Hypercontractile esophagus (Jackhammer)
Hypercontractile: DCI >8000 mmHg*s*cm
Absent Contractility
Failed Peristalsis: DCI <100 mmHg*s*cm

29. The Chicaco Classification V3.0: Hierarchical Analysis

30. Minor disorders of peristalsis
Ineffective esophageal
motility (IEM):
≥50% ineffective swallows.
Weak (DCI >100 <450 mmHg*s*cm)Failed: DCI <100 mmHg*s*cm
Fragmented Peristalsis:
≥50% fragmented
contractions (large
break >5 cm length)
with DCI > 450
mmHg*s*cm

31. The Chicaco Classification V3.0: Hierarchical Analysis

32. PROVOCATIVE TESTS

33. Multiple Rapid Swallow (MRS)
• Dependent on intact inhibitory and excitatory neural function
• Multiple swallow  profound inhibition of esophageal contraction + LES relaxation
• Last swallow of the series  a strong peristaltic contraction & LES after contraction
A) NORMAL RESPONSE
- Normal inhibition of
esophageal body
- LES relaxation
- Robust post-swallow
contraction
B) ABNORMAL RESPONSE
- Incomplete inhibition
showing contraction activity
during MRS (arrow)
C) FAILURE OF POST-MRS
CONTRACTION
- Suboptimal augmentation of
contraction after last
swallow

34. MRS can predict those at risk of
Dysphagia after Anti-reflux surgery
(Stoikes et al. Surg Endosc 2012)
Proportion of patients with normal MRS during HRM response highest in the
presence of dysphagia (p=0.02).
Abnormal MRS response during HRM help to predict dysphagia in patients
undergoing pre-operative manometric evaluation.

35. …because colorful is better!
THANK YOU VERY MUCH
FOR YOUR ATTENTION