Transcript SWALLOWING DISORDERS - Auckland District Health Board

DYSPHAGIA - THE ROLE OF
OESOPHAGEAL MOTILITY
DISORDERS
IAN WALLACE FCP(SA), FRACP.
SHAKESPEARE SPECIALIST GROUP
MILFORD, AUCKLAND
CAUSES OF DYSPHAGIA
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Stages of swallowing
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Oropharyngeal (Voluntary)
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Oesophageal (Involuntary)
CAUSES OF DYSPHAGIA
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HISTORY
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Oropharyngeal vs oesophageal body
Duration and frequency (progressive?)
Associated regurgitiation
Associated reflux symptoms
Solids to liquids vs solids and liquids
EXAMINATION
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Lymphadenopathy
Neurological
CAUSES OF DYSPHAGIA
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Structural abnormalities
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Oesophageal neoplasm
Peptic stricture
Shatzki ring
Incarcerated hiatal hernia
Oesophageal web
Oesophageal diverticulae
CAUSES OF DYSPHAGIA
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Motility disorders
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Non specific motility disorder
(ineffective oesophageal motility)
Achalasia
Eosinophilic oesophagitis
Nutcracker oesophagus
Diffuse oesophageal spasm
Hypertensive LOS
CAUSES OF DYSPHAGIA
MOTILITY DISORDERS
Dig Dis Sci 1987;32:583
Dysphagia in 132 patients
NSMD
nutcracker
DOS
HLOS
Achalasia
CAUSES OF DYSPHAGIA
MOTILITY DISORDERS
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Special investigations
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Baseline bloods
CXR
Endoscopy and mucosal biopsy
Barium swallow (marshmallow)
Oesophageal manometry
Normal Swallow
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High Resolution
Impedance-Manometry
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32 Pressure Channels
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Impedance Technology
Fundamentals
Alternating Current Generator
Current
Generator
Impedance Technology
Fundamentals
Reflux Bolus Conducts Electricity
&
Current Flows Between Impedance Rings
Current
Generator
Impedance Technology
Fundamentals
High Impedance
Low Impedance
No Reflux
Reflux
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
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4 Impedance
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Esophageal Body
Pharynx
UES
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Esophageal Body
LES
Gastric
Contour Plot View of Swallow with Normal Manometry & Complete Bolus Transit
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4 Impedance
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P
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Bolus Transit Waveforms
Manometry Waveforms
Contour Plot View of Swallow with Normal Manometry & Complete Bolus Transit
Impedance Technology Fundamentals
Bolus Entry
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m
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c
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Bolus Exit
Bolus Present
Time
Impedance Contacts
OESOPHAGEAL MOTILITY DISORDERS
INEFFECTIVE OESOPHAGEAL MOTILITY
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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
Oesophageal Motility Disorders
Achalasia-Aetiology
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Idiopathic- 98 %
Primary
 Secondary
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Familial
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Associated with other congenital
defects
Associated with degenerative
neurological disease
Oesophageal Motility Disorders
Achalasia - Symptoms
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Dysphagia – usually slowly progressive
Regurgitation
Chest pain and dysphagia
Reflux symptoms
Oesophageal Motility Disorders
Achalasia-Manometric features
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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
Normal Swallow
Achalasia Tracing
Oesophageal Motility disorders
Achalasia-Treatment
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Pneumatic dilatatation
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Botox injection
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Risks
Patient selection
Patient selection
Surgery
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Gastro-oesophageal reflux a
significant complication
Eosinophilic Esophagitis
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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 :
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GORD
Eosinophilic gastroenteritis
Collagen vascular diseases
Infections
Allergy Profile
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Allergy history
90%
Atopic illness
46%
Food allergy
25%
Family history of asthma
43%
 Blood eosinophils
36%
 IgE
56%
Positive RAST
42%
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
Eosinophilic Oesophagitis
Treatment Options
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Acid suppression (PPI therapy) where there are reflux
symptoms PLUS:
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Swallowed inhalers – e.g. fluticasone
Antihistamine therapy (Loratidine)
Corticosteroids
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Elimination diets where specific allergies are defined
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Role of Ranitidine
Clin Gastro. And Hepatol.2004;2:523 - 530
Eosinophilic Oesophagitis Conclusion
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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
OESOPHAGEAL MOTILITY
DISORDERS
NUTCRACKER OESOPHAGUS
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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.
Normal Swallow
Nutcracker Oesophagus
DYSPHAGIA
CONCLUSIONS
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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