Financial Disclosures

1. Esophageal ManometryKevin Kolendich, MDGastroenterology and HepatologyMissoula Medical ConferenceOctober 24th , 2014

2. Financial Disclosures No financial disclosures http://monkeyartawards.typepad.com/.a/6a00e55097ba24883401053619f88f970b-800wi

3. A Little Background on Me

4. St. Patrick Hospital St. Patrick Hospital is a 213-bed hospital with a level 2 trauma center. St. Patrick currently has 1,400 employees and 266 physicians.

5. St. Patrick Hospital • St. Patrick Hospital Motility Team. • Jenifer Alsbury, RN • Tamara Keogh, RN • Christi Brinda, RN • High volume motility center.

6. Esophageal Manometry

7. Esophageal ManometryDefinition A diagnostic test in which a thin tube is passed into the esophagus to measure the pressures exerted by the muscles of the esophagus over time during a swallow.

8. Is this how esophageal manometry appears to you? http://timothystotz.com/wp-content/uploads/2013/05/flowering-staircase-timothy-stotz.jpg

9. Once understood, manometry is so simple that anyone can do it http://weaponsman.com/wp-content/uploads/2013/12/DogOpeningDoor.jpg http://2.bp.blogspot.com/_BrhJY2UGYrE/S8zk98lUGOI/AAAAAAAAADU/jWC4zHes7LY/s400/Farside+-+pull.jpg

10. What are the learning objectives from today’s lecture?

11. Learning Objectives • Describe normal esophageal anatomy. • Understand the difference between water perfused manometry and solid state esophageal manometry.

12. Learning Objectives • Be able to properly identify and mark the following anatomic landmarks using high resolution manometry. • The upper esophageal sphincter (UES) • The esophageal body • The esophago-gastric junction (EGJ) • Be able to describe patient preparation for esophageal manometry.

13. Learning Objectives • Be able to describe how an esophageal motility catheter is placed. • Understand when to refer patients for esophageal manometry. • Know where to find resources to further your understanding of manometry.

14. Describe normal esophageal anatomy

15. Normal Esophageal Anatomy http://www.webmd.com/digestive-disorders/picture-of-the-esophagus

16. NormalEsophageal Anatomy • Upper Esophageal Sphincter (UES) • Cervical esophagus • Cricopharyngeus • Inferior pharyngeal constrictor http://classconnection.s3.amazonaws.com/231/flashcards/1157231/jpg/pharyngeal-muscles1328499814983.jpg

17. Normal Esophageal Anatomy • Esophageal body • The proximal 5% is striated muscle. • The middle 35%-40% is mixed (transition zone). • The distal 50%-60% is entirely smooth muscle. http://www.christinas-home-remedies.com/image-files/esophagus-anatomy.jpg

18. Normal Esophageal Anatomy • Muscular composition • Outer layer (longitudinal). • Inner layer (circular). • more precisely helical muscle. http://www.nature.com/gimo/contents/pt1/full/gimo6.html

19. Clinical Correlation • Clinical Correlation: • Presbyesophagus also known as tertiary contractions http://upload.wikimedia.org/wikipedia/commons/f/ff/Korkenzieher-%C3%96sophagus.jpg

20. Normal Esophageal Anatomy • There are three major contributors to the EGJ high pressure zone. • 1. The LES • 2. The crural diaphragm • 3. The muscular architecture of the gastric cardia http://www.nature.com/gimo/contents/pt1/images/gimo14-f1.jpg

21. Understand the difference between water perfused manometry and solid state esophageal manometry

22. Manometry • Water Perfusion Manometry (Conventional). • Every 5 cm • Solid State Manometry (High Resolution, 3D). • Every 1 cm http://www.upmc.com/patients-visitors/education/PublishingImages/G-L/EsophManometry-1.jpg

23. Equipment – Conventional Manometry • 8 channels, 4 are located 5 cm from the tip of the catheter with 4 other more proximal sensors spaced 5 cm apart. • 3.9 mm diameter.

24. Conventional Manometry

25. Equipment – High Resolution Manometry • All sensors are truly circumferential . • 36 channels spaced 1 cm apart 12 pressure sensing points at each channel (432 data points) . • Small diameter 2.75 mm. Source: http://www.sierrainst.com/manoscan360.html

26. High Resolution Manometry • Magenta end of color spectrum (hot colors) = highest pressure. • Blue end of color spectrum (cool colors) = lowest pressure.

27. High Resolution Manometry

28. Discuss the advantages high resolution manometry has over conventional esophageal manometry.

29. High Resolution Manometryvs. Conventional Manometry Conventional Manometry High Resolution Manometry Catheter stays in one position Solid state systems are relatively simpleand less cumbersome High fidelity Color contour No need for pull through: software creates an electronic sleeve for LES determination Hiatal hernias are easily identified Solid state catheters are soft and more comfortable Procedure takes less time Array of 36 channels straddle the entire esophagus, sees the entire organ • Need to move catheter for LES in most systems • Water-perfusion systems are multicomponent and cumbersome • Low fidelity • Waveforms only • LES measurements complex; some use sleeves, others need station pull-through technique • Hard to find hiatal hernias • Water-perfused catheters are stiff and more uncomfortable • Tests take longer • Large gaps between channels (5 cm)

30. High Resolution Manometryvs. Conventional Manometry

31. Patient Preparationfor High Resolution Esophageal Manometry

32. Pre-Pr0cedure Counseling • How do you describe esophageal manometry to a patient? • During esophageal manometry, a thin, pressure-sensitive, flexible tube is passed through your nose and into your stomach. • When the tube is in your esophagus, you will be asked to swallow. The pressure of the muscle contractions will be measured along the length of your esophagus. • The tube is removed after the test is completed. The test takes about 1 hour.

33. Pre-Pr0cedure Counseling • How do you tell patients to prepare for a manometry? • Patients should not have anything to eat or drink for 4-6 hours before the test (varies by center). • There is no need for bowel preparation. • Take all prescribed medications as usual. • This includes anticoagulants, aspirin, and NSAIDs, acid suppressive therapy.

34. Pre-Pr0cedure Counseling • How will the test feel? • Typically, the test is not uncomfortable. • Some patients may experience a gagging sensation when the tube is being placed.

35. How is an Esophageal Manometry Probe Placed?

36. Catheter Placement • Before bringing the patient into the room an RN performs a focused H&P and chart review. • Indication (dysphagia, chest pain, pre-operative evaluation, etc.) • Allergies (assure the patient isn’t allergic to lidocaine) • If they are use sterile lubricant jelly • Pertinent past surgeries (Nasal, esophageal, bariatric surgery etc.) • Make sure the patient did not eat or drink anything for 4 to 6 hours prior to test (this varies by center).

37. Catheter Placement • The patient is brought into the procedure room. • A gown is placed over their upper body and they sit on the edge of agurney. • The patient occludes each nostril and sniffs to determine if their right or left nostril is more patent. http://classconnection.s3.amazonaws.com/369/flashcards/1414369/png/assess_patency_of_nostrils1333807384492.png

38. Catheter Placement • The nostril is numbed with 2% lidocaine jelly using a 6-inch cotton tip applicator. • The manometric catheter is lubricated with 2% lidocaine. http://jan.ucc.nau.edu/daa/woundproducts/curasolgel3.jpg

39. Catheter Placement • The patient brings their chin down to their chest. • The catheter is advanced through the medicated nostril into the esophagus while the patient swallows. https://myhealth.alberta.ca/health/_layouts/healthwise/media/medical/hw/h9991890_001.jpg http://www.bartleby.com/107/Images/large/image855.gif

40. Catheter Placement • The manometric catheter is advanced until it crosses the lower esophageal sphincter and its distal tip is in the stomach. • The catheter is secured in place with tape. • The patient then lies supine on a gurney. http://www.upmc.com/patients-visitors/education/PublishingImages/G-L/EsophManometry-1.jpg

41. Catheter Placement • 5 ml of water (or saline) is placed into the patient’s mouth using a syringe. • The patient holds the liquid in their mouth then swallows once. • 30 seconds later this is repeated. • 10 wet swallows are performed. • The catheter is removed. http://www.robertsewellmd.com/Portals/2/Motility%20HD.jpg

42. Describe the manometric findings present during a normal swallow. 1. LES relaxation2. Normal esophageal peristalsis3. UES relaxation

43. The Esophagus at Rest

44. Manometry Tracing http://www.nature.com/ajg/journal/v105/n5/images/ajg2010165i1.gif

45. Name the indications for esophageal manometry

46. Indications • Dysphagia. • Non-cardiac chest pain. • Placement of intraluminal devices (e.g. pH probes). • Preoperative assessment of patients being considered for anti-reflux surgery and bariatric surgery. • Detecting esophageal motor abnormalities associated with systemic diseases (e.g. connective tissue diseases). American Gastroenterological Association Patient Care Committee on May 15, 1994

47. Dysphagia • The first step is to distinguish between oropharyngeal dysphagia and esophageal dysphagia. • Oropharyngeal dysphagia: • Arises from dysfunction of the pharynx and upper esophageal sphincter. • Esophageal dysphagia: • Arises from disorders of the esophageal body and lower esophageal sphincter.

48. Dysphagia Oropharyngeal Esophageal Have difficulty swallowing several seconds after initiating a swallow. Localize symptoms to the suprasternal notch or behind the sternum. May be associated with a history of food impaction or food “sticking” in the chest. • Have difficulty initiating a swallow. • Localize symptoms to the cervical region. • Frequently associated with coughing, choking, nasal regurgitation, and dysphonia.

49. What are some the appropriate questions to ask a patient with dysphagia in the office?

50. Dysphagia • Do you have problems initiating a swallow or do you feel food getting stuck a few seconds after swallowing? • Do you cough or choke or is food coming back through your nose after swallowing? • Do you have problem swallowing solids, liquids, or both? • How long have you had problems swallowing and have your symptoms progressed, remained stable, or are they intermittent?