Transcript part 2 - ncsgna

Demonstrate Real-Time HRM Pattern Recognition
• Intubation
• Folded Catheter
Intubation via HRM
Folded Catheter via HRM
What is Impedance and what does it
add to manometry and pH testing?
Combining real-time Bolus Transit & Muscle Function:
Visualize the liquid bolus as it is moved from the pharynx to the
stomach by the pressure gradients created during swallows
Pharynx-tostomach highresolution
pressure profile
Pharynx-tostomach highresolution liquid
bolus transit
profile
THE LIVING ESOPHAGUS ™
The Combined Uninterrupted Visualization of the RealTime Pressures & Resulting Bolus Transit of the Entire
Swallowing Anatomy
Normal Swallow Physiology :
Liquid Bolus (Gray) is stripped proximal-to-distal
by uninterrupted Pressure Wave (Red)
Pressure
Impedance
UES relaxes, bolus
quickly fills
esophagus
UES contracted,
Striated muscle wave
in progress, proximal
bolus stripped
Wave in
striated/smooth
transition zone, little
bolus movement
Distal smooth muscle
wave in progress,
bolus largely cleared
Wave reaches
level of LES, Bolus
cleared
High-Resolution Impedance Data Captured: (Normal Swallow)
Measurement of Full-Anatomy Pressures plus the Flow of Swallowed Liquid
(1) 36 fully-circumferential sensors and 18 fully-circumferential impedance liquid sensors simultaneously span
the entire swallowing anatomy in only one catheter position for the 10-minute study. Easily visualize (2) UES
relaxation and (3) UES closure during the swallow, as well as the (4) full-anatomy pressures (low-pressure blue
to high-pressure red) moving from pharynx to stomach. Easily visualize the (5) swallowed liquid (magenta)
being driven downward by these uninterrupted swallowing pressures, through the (6) LES as it relaxes, with the
liquid fully clearing into the stomach after (7) LES closure.
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3
Hot/High
Pressure
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4
4
Cold/Low
Pressure
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7
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The Chicago Classifications of Normal & Abnormal Swallows
Using Esophageal Pressure Topography
The Chicago Classifications of Motility Disorders
Using Esophageal Pressure Topography
Comparing Conventional Manometry and
High-Resolution Impedance Manometry:
Can Both Methods Accurately Diagnose
Motility Disorders?
A REVIEW OF THREE DISORDERS:
• Ineffective Esophageal Body Pressures w/Retrograde
Distal Spasm & Retrograde Bolus Escape (Reflux)
• Achalasia
• Hiatal Hernia
Conventional Manometry Data Captured:
(Unable to detect Ineffective Peristalsis with Bolus Entrapment)
Cannot Detect Ineffective Upper Esophageal Pressures and Lack of Swallow Transit
In this patient, since the sensors do not span the entire swallowing anatomy, the (1) upper
esophagus swallowing pressures appear normal. It is therefore assumed that swallowed liquids
are being effectively transported downward toward the stomach. However, the next slide of this
same patient studied with high-resolution impedance manometry reveals why this assumption is
incorrect.
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High-Resolution Impedance Data Captured:
(Accurately Detects Ineffective Peristalsis with Bolus Entrapment)
Reveals Ineffective Upper Esophageal Pressures and Ineffective Swallow Transit
In this same patient, (1) there is a 7-cm interruption in upper esophagus swallowing pressures
(low-pressure blue to high-pressure red), resulting in (2) swallowed liquid (magenta) entrapment.
(3) The lower esophagus then actually pressurizes backwards, causing the trapped liquid to then
(4) reflux backwards toward the mouth. This patient’s accurate diagnosis is non-peristaltic long
upper esophageal transition zone with retrograde spastic peristalsis and reflux.
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The Anatomy of Achalasia
Figure 4 Gross appearance of esophagus in classical achalasia.
GI Motility online (May 2006) | doi:10.1038/gimo20
Classic Achalasia “Bird’s Beak” and Dilated
Distal Esophagus via Barium Swallow
The Stages of Untreated Achalasia
B: 2 years
untreated
A: Early
Achalasia
GI Motility online (May 2006) | doi:10.1038/gimo53
C: End stage Achalasia with Megaesophagus
Conventional Manometry Data Captured: (Achalasia)
Cannot Detect Movement of Lower Sphincter or Transit of Swallowed Liquid
In this patient, the (1) lower esophageal sphincter shows a drop in pressure during
swallows. It is therefore assumed that the sphincter is relaxing, allowing swallowed
liquids to transport effectively through the sphincter and into the stomach. However,
the next slide of this same patient studied with high-resolution impedance
manometry reveals how this assumption is incorrect.
1
High-Resolution Pressure Data Captured: (Achalasia)
Detects Movement of Lower Sphincter and Ineffective Transit of Swallowed Liquid
In this patient, the sensors that span the entire anatomy easily reveal that the (1)
lower esophageal sphincter actually moves upward during esophageal shortening, and
(2) does not relax (note the non-relaxing LES pressure remains hypertensive at 73 mm
Hg). The next slide (with the impedance data displayed) reveals the resulting complete
lack of bolus transit.
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1
High-Resolution Impedance Data Captured: (Achalasia)
Reveals the Resulting Ineffective Transit of Swallowed Liquid
As a result of the non-relaxing lower esophageal sphincter, the (1) tight sphincter (Bird’s Beak)
prevents swallowed liquids (magenta) from transporting effectively through the sphincter and
into the stomach. There is a (2) complete lack of any esophageal swallowing pressures (blue to
red), which further results in a (3) complete entrapment of swallowed liquid (magenta). This, in
combination with the non-relaxing lower sphincter yields an accurate diagnosis of Classic
Achalasia (Type II).
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3
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Hiatal Hernia
Conventional Manometry Data Captured: (Hiatal Hernia)
Nearly Impossible to Detect Hiatal Hernia
In this patient, the swallow looks normal. And due to the limited number of pressure
sensors, there is no observable hiatal hernia, which occurs when there is a hole in the
diaphragm and a portion of the stomach herniates upward into the chest cavity, with a
resulting separation of the lower esophageal sphincter from the diaphragm. However,
the next slide of this same patient studied with high-resolution manometry reveals the
obvious presence of a hiatal hernia, and the resulting pressures that are the cause of
this patient’s previously-diagnosed reflux.
High-Resolution Impedance Data Captured: (Hiatal Hernia)
Easy to Detect Hiatal Hernia
As a result of sensors that span the entire swallowing anatomy, a (1) 4.2 cm hernia sac (light blue
span) is easily seen with a separation between the (2) lower sphincter and the (3) diaphragm.
This patient refluxes because the (4) diaphragm pinch pressure during inspiration is 19 mmHg and
causes retrograde movement of sac contents across the (5) hypotensive LES barrier pressure of
only 3 mmHg.
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