DYSPHAGIA - THE ROLE OF OESOPHAGEAL MOTILITY DISORDERS

1. DYSPHAGIA - THE ROLE OF OESOPHAGEAL MOTILITY DISORDERS IAN WALLACE FCP(SA), FRACP. SHAKESPEARE SPECIALIST GROUP MILFORD, AUCKLAND

2. CAUSES OF DYSPHAGIA • Stages of swallowing • Oropharyngeal (Voluntary) • Oesophageal (Involuntary)

3. CAUSES OF DYSPHAGIA • HISTORY • Oropharyngeal vs oesophageal body • Duration and frequency (progressive?) • Associated regurgitiation • Associated reflux symptoms • Solids to liquids vs solids and liquids • EXAMINATION • Lymphadenopathy • Neurological

4. CAUSES OF DYSPHAGIA • Structural abnormalities • Oesophageal neoplasm • Peptic stricture • Shatzki ring • Incarcerated hiatal hernia • Oesophageal web • Oesophageal diverticulae

5. CAUSES OF DYSPHAGIA • Motility disorders • Non specific motility disorder (ineffective oesophageal motility) • Achalasia • Eosinophilic oesophagitis • Nutcracker oesophagus • Diffuse oesophageal spasm • Hypertensive LOS

6. CAUSES OF DYSPHAGIAMOTILITY DISORDERS Dig Dis Sci 1987;32:583

7. CAUSES OF DYSPHAGIAMOTILITY DISORDERS • Special investigations • Baseline bloods • CXR • Endoscopy and mucosal biopsy • Barium swallow (marshmallow) • Oesophageal manometry

8. Normal Swallow

9. 29 28 High Resolution Impedance-Manometry 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 32 Pressure Channels 9 8 7 6 5 4 3 2 1 0 -1 -2 -3 -4 -5 -6

10. Alternating Current Generator Current Generator Impedance Technology Fundamentals

11. Current Generator Impedance Technology Fundamentals Reflux Bolus Conducts Electricity & Current Flows Between Impedance Rings

12. High Impedance Low Impedance No Reflux Reflux Impedance Technology Fundamentals

13. Impedance Technology Fundamentals A single impedance channel will detect bolus movement through the oesophagus Multiple impedance channels are required to detect the direction of bolus movement

14. 1 2 3 4 5 6 Impedance Esophageal Body P r e s s u r e Pharynx UES Esophageal Body LES Gastric Contour Plot View of Swallow with Normal Manometry & Complete Bolus Transit

15. 1 2 3 4 5 6 Impedance Bolus Transit Waveforms P r e s s u r e Manometry Waveforms Contour Plot View of Swallow with Normal Manometry & Complete Bolus Transit

16. Bolus Entry Bolus Exit Bolus Present Impedance Technology Fundamentals Impedance Time Impedance Contacts

17. OESOPHAGEAL MOTILITY DISORDERSINEFFECTIVE OESOPHAGEAL MOTILITY • Common in patients with chronic reflux • Predictive of refractory nocturnal GORD • Characterized by a hypo contractile oesophagus. (amplitude <30mmHg in >30% of contractions) • Failure of distal propagation of peristaltic wave

18. Oesophageal Motility Disorders Achalasia-Aetiology • Idiopathic- 98 % • Primary • Secondary • Familial • Associated with other congenital defects • Associated with degenerative neurological disease

19. Oesophageal Motility Disorders Achalasia - Symptoms • Dysphagia – usually slowly progressive • Regurgitation • Chest pain and dysphagia • Reflux symptoms

20. Oesophageal Motility Disorders Achalasia-Manometric features • Normal to raised LOS resting pressures • LOS fails to relax to gastric baseline • Raised residual pressures • Raised oesophageal baseline pressures • Absent or chaotic low amplitude simultaneous peristalsis

21. Normal Swallow

22. Achalasia Tracing

23. Oesophageal Motility disorders Achalasia-Treatment • Pneumatic dilatatation • Risks • Patient selection • Botox injection • Patient selection • Surgery • Gastro-oesophageal reflux a significant complication

24. Eosinophilic Esophagitis • Definition: Presence of eosinophils in the squamous epithelium or deeper • Number of Eosinophils/hpf ranged from 30 – 320 (mean 101) • Various studies have used 15-30/hpf • Oesophagus - an immunologically active organ • Eosinophilic infiltration also seen in : • GORD • Eosinophilic gastroenteritis • Collagen vascular diseases • Infections

25. Allergy Profile • Allergy history 90% • Atopic illness 46% • Food allergy 25% • Family history of asthma 43% •  Blood eosinophils 36% •  IgE 56% • Positive RAST 42%

26. Endoscopic features associated with EE • Nonerosive changes extending along the whole esophagus • Whitish pinpoint exudate or papules • Granularity • Loss of vascular pattern • Linear furrow and fold pattern • Rings • Corrugation • Focal stricture (often proximal) • Long-segment stricture (small caliber esophagus) • Linear sheering of mucosa after dilation

29. Eosinophilic OesophagitisTreatment Options • Acid suppression (PPI therapy) where there are reflux symptoms PLUS: • Swallowed inhalers – e.g. fluticasone • Antihistamine therapy (Loratidine) • Corticosteroids • Elimination diets where specific allergies are defined • Role of Ranitidine Clin Gastro. And Hepatol.2004;2:523 - 530

30. Eosinophilic Oesophagitis - Conclusion • EE, a condition seen in children now increasing identified in adults • Should be considered in the relevant patient population & those not responding to standard reflux treatment • Awareness and recognition of gross changes by endoscopists • Importance of tissue sampling for subtle abnormalities • Establishing correct diagnosis may prevent unnecessary interventions, e.g. fundoplication

31. OESOPHAGEAL MOTILITY DISORDERSNUTCRACKER OESOPHAGUS • Most common cause of NCCP in those patients with an oesophageal motility disorder. • Average distal pressures > 180 mm Hg. • Peristalsis is normal so Ba studies usually normal. • 90% present with chest pain.

32. Normal Swallow

33. Nutcracker Oesophagus

34. DYSPHAGIACONCLUSIONS • The symptom of dysphagia does not always indicate a physical obstruction • Oesophageal motility disorders account for the majority of cases of dysphagia • A normal endoscopy or Ba study does not exclude a motility disorder - role of oesophageal manometry • Importance of mucosal biopsies of macroscopically normal mucosa