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.

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.

Esophageal Motility

 Three separate stages: – Voluntary or oral stage.

– Pharyngeal stage.

– Esophageal stage.

Esophageal Motility

Esophagus Diagnostic procedures

  Morphologic diagnostics – Esophageal radiography – Endoscopy – Pill cam ESO Functional diagnostics – Esophageal manometry – Esophageal pH monitoring – Esophageal impedance – Radionuclide 99 mTC scintiscanning

Esophageal Manometry

 When does it help?

– Functional disorder is suspected – Unrevealing morphological studies – Part of pre-operative evaluation

Water Perfused System

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

Solid state Catheters

 Catheters have miniature strain gauge transducers built into the catheter to generate electrical output signals

Solid State Catheters

  Advantages – Fast response – No water perfusion – Easy to use and calibrate Disadvantages – Expensive – Limited number sensors – Fragile – Functional lifespan

Esophageal Manometry

 Three steps: – LES – Body – UES

Esophageal Manometry

ManoScan ™ Overview / HRM

    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

Normal Study Using ManoScan ™ Line Trace Mode

UES LES

Normal study

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

Esophageal manometry

  24 hour pH confirmed acid reflux Proceeded with surgery for management of GERD

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?

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”

Achalasia

Dilated esophagus Bird beak appearance

Achalasia

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

Achalasia - Management

  Endoscopic: – botulinum toxin injection of LES, pneumatic dilation of LES Surgical: – Hellers myotomy (usually with anti reflux fundoplication)

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?

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

DES

  Rosary Bead or corkscrew esophagus Treatment: – CCB (diltiazem) – nitrates (isosorbide) – Sildenafil – TCA (imipramine)

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)

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?

Scleroderma

 Pathophysiology: – alterations of the microvasculature, the autonomic nervous system, and the immune system, leading to fibrosis – Affects lower 2/3 of esophagus

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

Esophageal Impedance

Esophageal motility disorders

  Primary disorders – Achalasia – Diffuse esophageal spasm – Nutcracker esophagus – Ineffective motility disorder Secondary disorders – Scleroderma

  Disclosure: none Questions