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Il sottoscritto EDOARDO SAVARINO in qualit à di docente dell ’ evento sopra indicato, ai sensi dell ’ art. 3.3 sul Con

Il sottoscritto EDOARDO SAVARINO in qualit à di docente dell ’ evento sopra indicato, ai sensi dell ’ art. 3.3 sul Conflitto di Interessi, pag. 17 del Reg. Applicativo dell ’ Accordo Stato-Regioni del 5/11/09, per conto del provider I&C srl dichiara che negli ultimi due anni

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Il sottoscritto EDOARDO SAVARINO in qualit à di docente dell ’ evento sopra indicato, ai sensi dell ’ art. 3.3 sul Con

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  1. Il sottoscritto EDOARDO SAVARINO in qualità di docente dell’evento sopra indicato, ai sensi dell’art. 3.3 sul Conflitto di Interessi, pag. 17 del Reg. Applicativo dell’Accordo Stato-Regioni del 5/11/09, per conto del provider I&C srl dichiara che negli ultimi due anni non ha avuto rapporti con soggetti portatori di interessi commerciali in campo sanitario

  2. ImpattodelleTecnologiesullagestioneclinica:pH e Manometry-Impedance Dott. Edoardo V. Savarino Dipartimento di Medicina Interna, Clinica di Gastroenterologia con Endoscopia Digestiva, Università di Genova (Resp. Prof. V. Savarino)

  3. Combined impedance-manometry 17 cm 15 cm 9 cm 7 cm 5 cm pH - 5 cm 3 cm NEW TECHNOLOGIES 6 impedance channels 20cm 20cm 1 pH channel 15cm 15cm 10cm 10cm Esophageal pH monitoring without catheter 5cm 5cm LES

  4. Impedance Monitoring Kahrilas PJ.

  5. Impedance Monitoring: When? Non-Cardiac Chest Pain – Disphagia – Globus • Evaluationofpatientswithdifficultsymptoms • Evaluationofsymptomaticpatientsdespite PPI therapy • Evaluationofatypical GERD (Correlate acid & nonacid GER episodes to Sx and quantify proximal extent of GER) • Pre and Post-operativeevaluationofpatientsconsideredforsurgery • Evaluationof GERD in infants and pediatricpatients • Evaluationofnewmedical or endoscopictherapiesfor GERD (Baclofen, Esophyx, Arbaclofen, Lesogaberan etc.) EfficacyofMedical Therapy – Correlate Acid & Non-Acid GER toSx – Absenceofabnormal GER Cough – Asthma – Laryngitis – Hoarseness – Bronchitis - Dysfonia – Interstitial Lung Disease Pathological acid exposure – Symptom-refluxAssociation – Efficacyofsurgery Pathological non-acid exposure – Nocturnal apnea

  6. Main Diagnostic Advantage Does patient have a reflux disease? MII-pH Impedance Monitoring In case of normal acid exposure Positive Symptom Association Negative Symptom Association Identify Non-Acid Reflux Disease Identify Functional Diseases or search for other causes

  7. NERDPatients (N = 150) Normal AcidExposure Time 87 (58%) Abnormal Acid Exposure Time 63 (42%) Positive SI 54 (36%) Negative SI 9 (6%) Positive SI 45 (30%) Negative SI 42 (28%) Functional Heartburn 42 (28%) Acid Only 48 (32%) Acid Only 20 (13%) Acid and Nonacid 4 (3%) Acid and Nonacid 7 (5%) Nonacid Only 18 (12%) Nonacid Only 2 (1%) Total Acid 52 (35%) Total Acid 27 (18%) Total Nonacid 25 (17%) Total Nonacid 6 (4%) Clinical Utility ofImpedance-pH in NERD patients Savarino E et al. Am J Gastroenterology 2008;103:1-9

  8. The AddedValueofImpedance-pHtoRome III Criteria in NERD patients (N=219) % of patients 3% 10% NARD Savarino E et al. Dig Liv Dis 2011; March 2

  9. RomeCriteria 3 ½ Kahrilas PJ et al. Am J Gastroenterology 2010;747:756

  10. Acid Only 35 (60%) Acid Only 3 (5%) Acid and Nonacid 3 (5%) Acid and Nonacid 5 (9%) Nonacid Only 4 (7%) Nonacid Only 4 (7%) Total Acid 40 (69%) Total Acid 6 (10%) Total Nonacid 9 (16%) Total Nonacid 7 (12%) EEPatients (N = 58) Clinical Utility ofImpedance-pH in EE patients Normal Acid Exposure Time 11 (19%) Abnormal Acid Exposure Time 47 (81%) Positive SAP 44 (76%) Negative SAP 3 (5%) Positive SAP 10 (17%) Negative SAP 1 (2%) Savarino E et al. Am J Gastroenterology 2010; 105:1053-61

  11. Clinical Utility ofImpedance-pH in EE patients “Gastric acid secretion persists despite ongoing PPI therapy and activated pepsins may well be present in weakly acidic refluxes. Therefore, they may be responsible for mucosal damage. Therapeutic interventions in patients with PPI-resistant reflux oesophagitis should be tailored on the basis of impedance–pH-monitoring results” Frazzoni M et al. APT 2011; 33:601-606

  12. Impedance-pH and overlapsyndromes Savarino E et al. Gut 2009; 58:1185-1191

  13. Impedance-pH and overlapsyndromes NERD HE FH NERD * * * * = p <0.01 * % of patients Savarino E et al. Gut 2009; 58:1185-1191

  14. Impedance-pH and newdrugs *p<0.05 * * * *

  15. Impedance-pH and newdrugs

  16. Impedance-pH and surgery

  17. Impedance-pH and surgery • Patientsselection: • 15 haderosive esophagitis • 16 hadnon-erosive reflux disease LaparoscopicNissenFundoplication ↓ Number of total, acid and weakly acidic reflux episodes ↓ Acid exposure time, liquid and mixed reflux events ↓ Gatric belching, but ↑ Supragastric belching 16 Patients were asymptomatic 15 Patients were symptomatic, but with negative SI for acid or weakly acidic reflux

  18. Impedance-pH and surgery No symptom was registered during the study performed after intervention 38 were totally asymptomatic Subtotal symptom remission was reported by two patients, one with a postoperative heartburn score of 1 (3 before intervention) and one with a post-operative regurgitation score of 1 (3 before intervention)

  19. Impedance-pH: On or Off-PPI Therapy? Twice-daily PPI Therapy for at least 2 months Impedance-pHTesting On Therapy

  20. Impedance-pH: On or Off-PPI Therapy? N=30 Hemmink et al. Am J Gastroenterology 2008; 103:2446-53

  21. Impedance-pH: On or Off-PPI Therapy? Impedance Impedance-pH as the gold standard to clarify the relationship between symptoms and reflux Impedance-pH as the gold standard to test if the patient has or not GERD in the first place Off Therapy On Therapy History of Erosive esophagitis or Barrett Esophagus Previous positive conventional pH monitoring Modified by Tutuian R. J Gastrointestin Liver Dis 2009; 1:9-10

  22. Esophageal body LES resting pressure LES residual pressure Achalasia 100% aperistalsis elevated / normal elevated / normal IEM > 30% ineffective contractions normal / low normal DES > 20% simultaneous swallows normal / elevated normal Normal < 30% ineffective normal normal < 20% simultaneous Nutcracker normal; DEA >180mmHg normal / elevated normal / elevated Hypertensive LES > 45 mmHg normal elevated / normal Poorly relaxing LES normal normal > 8 mmHg Hypotensive LES normal < 10 mmHg normal DefinitionofMotilityAbnormalities IEM – ineffective esophageal motility DES – distal esophageal spasm LES – lower esophageal sphincter Spechler & Castell. Gut 2001; 49:145-51

  23. Meaningof esophageal motilityabnormalities ?

  24. Motility Assessment Criteria Pressure Measurements Bolus Transit Measurements Esophageal Body Contraction Amplitude LES Resting Pressure Complete Incomplete Esophageal Body Contraction Velocity LES Residual Pressure Esophageal Function TestingCombined Impedance-Manometry Comprehensively Assesses Esophageal Function

  25. Impedance-Manometry Testing 20cm 20cm 15cm 15cm 10cm 10cm 5cm 5cm LES

  26. Video-fluoro vs. Impedance r = 0.94 Simren et al. Gut 2003; 52:784-790

  27. Bolus Transit Complete bolus transit Bolus retention at 15cm 20 cm 15 cm 10 cm 5 cm 2 cm

  28. Patients with esophageal motility abnormalities • 350 patients • Females 220 (63%), males 130 (37%) • Age: mean 53.5 years, range 12-86 years Tutuian R et al. Am J Gastroenterology 2004; 99:1011-9

  29. Percentage of Patients with normal bolus transit for liquid based on manometric diagnosis (n=350) Tutuian R et al. Am J Gastroenterology 2004; 99:1011-9

  30. Impedance-manometry classification of motility abnormalities Mild Moderate Severe Pressure and Transit Pressure only Achalasia Scleroderma Nutcracker Hypertensive LES Hypotensive LES Poor relaxing LES IEM DES Tutuian R et al. Am J Gastroenterology 2004; 99:1011-9

  31. 40% 40% 40% 30% 30% 30% 20% 20% 20% 10% 10% 10% 0% 0% 0% 10% 10% 10% 20% 20% 20% 30% 30% 30% 40% 40% 40% 20 15 10 5 2 Frequencyofbolusretentionat different levels in the esophagus (n=67 patients) (Bread) p<0.05 at each level Dysphagia Chest-pain GERD % swallows with bolus retention DDW 2007, Washington, USA

  32. Manometric Findings in 755 GERD Patients and 48 HVs FISMAD 2011, Torino, Italy N=48 N=70 N=239 N=340 N=106 AUMENTO DELL’INCIDENZA DIIEMCON L’AUMENTARE DELLA SEVERITA’ DELLE LESIONI Simile prevalenza di IEM tra HV e FH

  33. Bolus Transit for Liquid Swallows in GERD Patients • Bolus Transit alterato in Pazienti con lesionivisibiliendoscopicamente Valori simili tra FH e NERD FISMAD 2011, Torino, Italy

  34. Manometric Diagnosis with Bolus Transit in GERD Patients Patients (%) FISMAD 2011, Torino, Italy

  35. Future Issues to be Elucidated • The impact of Bolus Transit assessment in patients undergoing esophageal surgery (Fundoplication, Heller Miotomy, Trans-oral esophageal diverticulectomy etc.) • The diagnostic utility of Bolus Transit assessment in patients with non-obstructive dysphagia (functional dysphagia etc.) • The impact of Bolus Transit assessment in studies aimed at testing future drugs for improving gastro-esophageal emptying (Bolus transit time)

  36. Thankyouforyourattention!

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