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6/14/2016
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Esophageal Manometry: Easier to Swallow than you think
James Callaway, MD
Assistant Professor
Division of Gastroenterology
University of Alabama at Birmingham
Objectives:
• Review basics of esophageal high resolution manometry
• Discuss steps and interpretation of swallows and peristalsis
• Review the 2015 Chicago Classification for Esophageal Motility Disorders
Case
• 74 year old woman with 8 years of recurrent nausea, vomiting and dysphagia. EGDs with dilations in the past with minimal help.
• PMH: DM, COPD, CKD, fibromyalgia on chronic opiates
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Mild dilation of the esophagus. Contrast does intermittently enter the stomach.
Non-propulsive lumen occluding contractions noted in the distal 1/3 of the esophagus with intermittent relaxation of the LES.
Swallow 4: More of a normal appearing peristaltic wave but significant LES hypercontractility after swallow. Impaired LES relaxation.
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Swallow 8: Some evidence of peristalsis. Impaired LES relaxation at swallowOnset. Much of hypertension localized to LES.
Swallow 9: Spastic/simultaneous contraction with significant post-deglutitiveLES hypercontractility
Dx: EGJ outflow obstruction
Endoscopy
• EGD – Normal appearing esophagus. No dilation of retained food/liquid. Possibly tight LES.
• EUS – Circumferential hypertrophy of the LES without invading mass. Expansion of the submucosa also seen circumferentially.
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Clinical Course
• Nifedipine added with 3‐4 weeks of improvement but not resolution
• EGD with BOTOX to the LES performed.
• 1 month Follow up: Resolution of regurgitation. Continues to have mild solid food dysphagia. Remains on opiates.
Pandolfino, ATC, 2011
Conventional vs. High Resolution
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Normal Appearing Swallow
Same swallow – Impedance enabled – Bolus cleared
Distal Contractile Integral = 5018Normal contraction vigor/strengthLess/No emphasis placed on morphology
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Steps for Swallow Analysis– done separately for all 10 swallows
1. Lower esophageal sphincter
2. Contraction Vigor
Too much, too little, or just right
3. Contraction Pattern
Spasm
Breaks in normal peristalsis
Panpressurization
4. Impedance analysis
Lower Esophageal Sphincter
• Basal or resting pressure
– Low vs. High vs. Normal
• Relaxation
– Appropriate or not
– Measured by integrated relaxation pressure (IRP)
Integrated Relaxation Pressure (IRP)
• mmHg
• Mean of the 4 s of maximal deglutitiverelaxation in the 10‐s window beginning at UES relaxation.
• Contributing times can be continuous or non‐continuous.
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Integrated Relaxation Pressure (IRP)
Steps for Evaluating a Swallow
1. Lower esophageal sphincter
2. Contraction Vigor
Too much, too little, or just right
Contraction Pattern
Spasm
Breaks in normal peristalsis
Panpressurization
3. Hiatal hernias
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Distal Contractile Integral = 5018Normal contraction vigor/strengthLess/No emphasis placed on morphology
Contraction Vigor/Contractility
Contraction Vigor
Failed DCI < 100 mmHgscm
Weak DCI > 100, but < 450 mmHgscm
Ineffective Failed or Weak
Normal DCI > 450, but < 8,000 mmHgscm
Hypercontractile DCI >8,000 mmHgscm
Chicago Classification (v3.0)
Distal contractile integral = 259.4 (normal 450-8000)Weak
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Distal contractile integral – 94.3 (normal 450-8000)Failed
Distal Contractile Integral – 10725.3Hypercontractile
Steps for Evaluating a Swallow
1. Lower esophageal sphincter
2. Contraction Vigor
Too much, too little, or just right
3. Contraction Pattern
Spasm
Breaks in normal peristalsis
Panpressurization
4. Hiatal hernias
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Modified from R. Goyal and R. Shaker, GI Motility Online, Sleisenger and Fordtran, 2015
Distal Latency
Sleisenger and Fordtran, 2015
Distal Latency (sec)
• Definition:
– Interval between UES relaxation and the contraction deceleration point (CDP)
– Normal is >4.5 seconds
– < 4.5 seconds defines a premature contraction
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Contraction Deceleration Point (CDP)
• Definition
– The inflection point along the 30mmHg isobaric contour at which propagation velocity slows
– Demarcates esophageal peristalsis from ampullaryemptying
– Must be within 3 cm of proximal margin of LES
– Distal latency metric based on this point
Contraction Deceleration Point
Breaks – Large and Small
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Impedance enable – poor bolus clearance
Break in the 20 mmHg isobaric contour line
Esophageal Contractility
Contraction pattern
Premature DL < 4.5 s
Fragmented Large break (>5cm in length) in the 20‐mmHg isobaric contour with DCI >450
Intact Not achieving the above diagnostic criteria
Contraction pattern is not scored for ineffective swallows [DCI <450 mmHgscm]
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Esophageal Contractility
Intrabolus Pressure Pattern [30 mmHg isobaric contour referenced to atmospheric]
Panesophageal Pressurization Uniform pressurization of >30mmHg extending from the UES to the EGJ
Compartmentalized esophageal pressurization
Pressurization >30 mmHg extending from the contractile front to the EGJ
EGJ Pressurization Pressurization restricted to zone between the LES and CD in conjunction with LES‐CD separation
Normal No bolus pressurization >30mmHg
Recap: Steps for Evaluating a Swallow
1. Lower esophageal sphincter
2. Contraction Vigor
Too much, too little, or just right
3. Contraction Pattern
Spasm
Breaks in normal peristalsis
Panpressurization
4. Impedance analysis
The Chicago Classificationof Esophageal Motility Disorders,
v3.0
Pandolfino et al. Neurogastroenterology and Motility, February 2015
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History
• 2009, 1st edition
• 2012, 2nd edition
• 2015, v3.0
– Endorsed by the American Neurogastroenterologyand Motility Society & the European Society of Neurogastroenterology and Motility
The Chicago Classification of esophageal motility (v3.0)
• Type I achalasia (classic achalasia)
• Type II achalasia (with esophageal compression)
• Type III achalasia (spastic achalasia)
• EGJ outflow obstruction
Achalasia and EGJ outflow obstruction
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v3.0• Major Disorders of Peristalsis
– Absent Contractility
– Distal Esophageal Spasm
– Hypercontractile esophagus (Jackhammer)
• Minor Disorders of Peristalsis
– Ineffective esophageal motility (IEM)
– Fragmented peristalsis
• Normal esophageal motility
Type I or “Classic” Achalasia
Type II Achalasia
Achalasia with esophageal compression
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Type III Achalasia
Spastic Achalasia
Achalasia Subtypes
Sleisenger and Fordtran, 2015
EGJ Outflow Obstruction
Type IV Achalasia?? probably more heterogenous
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IRP 22.4
EGJ Outflow Obstruction
• Achalasia ‐ Early
• Pseudoachalasia
• Stricture
• Paraesophageal hernia
• Sarcoidosis
• EoE?
• External compression – vascular, etc.
Absent Contractility
• Normal median IRP, 100% failed peristalsis
• Achalasia should be considered when IRP values are borderline and when there is evidence of esophageal pressurization
• Premature contractions with DCI values less than 450 meet criteria for failed peristalsis
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Distal Esophageal Spasm
• Normal median IRP, ≥ 20 premature contractions with DCI > 450. Some normal peristalsis may be present
Distal Esophageal Spasm
• ?muscular hypertrophy
• ?Selective, intermittent dysfunction of myenteric plexus inhibitory neurons
• Impaired deglutitive inhibition
• Bolus transit impaired as with type III achalasia dysphagia
Hypercontractile Esophagus(jackhammer)
• At least two swallows with DCI >8000
• Hypercontractility may involve, or even be localized to the LES
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Ineffective Esophageal Motility (IEM)
• Previous definition in convention manometry
– 50% or more ineffective swallows
• Defined as contractions exhibiting amplitudes <30mmHg at pressure sensors positioned 3 and 8 cm above the LES
• Now defined as ≥ 50% ineffective swallows
– Can be failed or weak (DCI < 450 mmHgscm)
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Questions??
James Callaway, MD
Mailing Address:
BDB 380
1720 2nd Ave South
Birmingham, AL 35294
UAB MIST: 205‐934‐3411
Two separate pressure points around the LESHiatal hernia
6.3 cm Hiatal hernia
