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Esophageal Manometry

Esophageal Manometry. Chhaya Hasyagar, MD Gastroenterology Kaiser, Sacramento. Objectives. Review esophageal anatomy Role of esophageal manometry testing Review manometry tracings. Anatomy. 18- to 25-cm long muscular tube cervical and thoracic parts.

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Esophageal Manometry

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  1. Esophageal Manometry Chhaya Hasyagar, MD Gastroenterology Kaiser, Sacramento

  2. Objectives • Review esophageal anatomy • Role of esophageal manometry testing • Review manometry tracings

  3. Anatomy • 18- to 25-cm long muscular tube • cervical and thoracic parts. • wall is composed of striated muscle in the upper part, smooth muscle in the lower part, and a mixture of the two in the middle.

  4. Esophageal Motility • Three separate stages: • Voluntary or oral stage. • Pharyngeal stage. • Esophageal stage.

  5. Esophageal Motility

  6. Esophagus Diagnostic procedures • Morphologic diagnostics • Esophageal radiography • Endoscopy • Pill cam ESO • Functional diagnostics • Esophageal manometry • Esophageal pH monitoring • Esophageal impedance • Radionuclide 99 mTC scintiscanning

  7. Esophageal Manometry • When does it help? • Functional disorder is suspected • Unrevealing morphological studies • Part of pre-operative evaluation

  8. Water Perfused System

  9. Water Perfused System • Advantages • Cost effective • Flexibility in configuration • Disadvantages • Slow response rate • Less suitable for UES and pharynx • Need for skilled personnel for use and maintenance

  10. Solid state Catheters • Catheters have miniature strain gauge transducers built into the catheter to generate electrical output signals

  11. Solid State Catheters • Advantages • Fast response • No water perfusion • Easy to use and calibrate • Disadvantages • Expensive • Limited number sensors • Fragile • Functional lifespan

  12. Esophageal Manometry • Three steps: • LES • Body • UES

  13. Esophageal Manometry

  14. ManoScan™ / HRM Overview • Automatically captures all motor function from pharynx to stomach • Reduces data acquisition times by more than 60% • Simplifies procedures and technician training • Yields portable & reproducible data sets

  15. Normal Study UsingManoScan™ Line Trace Mode UES LES

  16. Normal study

  17. Case 1 • 48 year old female with long standing heartburn • Symptoms well controlled on PPIs for 5 years • Now with recurrence of symptoms despite high dose PPI • EGD: hiatal hernia otherwise normal

  18. Esophageal manometry • 24 hour pH confirmed acid reflux • Proceeded with surgery for management of GERD

  19. Case 2 • 36 year old archeologist with gradual onset of fatigue and dysphagia. • Difficulty with drinking water • Returned from a trip to the Amazon basin 6 months ago • EGD: Normal except for a “pop” felt while advancing scope into the stomach • Next step?

  20. HREM • Aperistalsis in the smooth muscle portion of the body of the esophagus. • elevated resting LES pressure: >45 mmHg • incomplete LES relaxation after a swallow • “common channel effect”

  21. Achalasia Dilated esophagus Bird beak appearance

  22. Achalasia • Idiopathic or acquired – Chagas disease • Increases risk of squamous cell CA • Chagas disease – parasite Trypanosoma cruzi, transmitted by “kissing bug”

  23. Achalasia - Management • Endoscopic: • botulinum toxin injection of LES, pneumatic dilation of LES • Surgical: • Hellers myotomy (usually with anti-reflux fundoplication)

  24. Case 3 • 50 year old female seen in the ER 4 times with sudden onset of chest pressure. • Cardiac workup including stress test was negative • EGD: normal • Next step?

  25. Diffuse esophageal Spasm (DES) • Frequent simultaneous contractions (>20-30%) with interval normal contractions. • Confined distal 2/3. • Multiphasic waves. • Prolonged duration. • Spontaneous contractions • High amplitude of the contractions

  26. DES • Rosary Bead or corkscrew esophagus • Treatment: • CCB (diltiazem) • nitrates (isosorbide) • Sildenafil • TCA (imipramine)

  27. Nutcracker Esophagus • high amplitude peristaltic contractions in the distal 10 cm of the esophagus • average distal esophageal peristaltic pressures >220 mmHg • Increased distal peristaltic duration (mean value >6 sec)

  28. Case 4 • 55 year old female with intolerance to cold, heartburn not responding to medications, with c/o dysphagia to solids for 8 months • Wears gloves in summer as her fingers turn blue to purple in AC rooms • Upper endoscopy: normal, no webs or rings • Next step?

  29. Scleroderma • Pathophysiology: • alterations of the microvasculature, the autonomic nervous system, and the immune system, leading to fibrosis • Affects lower 2/3 of esophagus

  30. Esophageal impedance • Measures changes in resistance to alternating electrical current when a bolus passes through a ring • Liquid containing boluses will lower the impedance to a nadir value • Gas will produce a rapid rise in impedance

  31. Esophageal Impedance

  32. Esophageal motility disorders • Primary disorders • Achalasia • Diffuse esophageal spasm • Nutcracker esophagus • Ineffective motility disorder • Secondary disorders • Scleroderma

  33. Disclosure: none • Questions

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