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TECNICHE DIAGNOSTICHECONVENZIONALI PER LO STUDIO DELLA DISFAGIA

LA MANOMETRIA ESOFAGEA

Michele Di Stefano

Clinica Medica 1°Fondazione IRCCS Policlinico “S.Matteo”

Università di PaviaPavia

STATIONARY ESOPHAGEAL MANOMETRY

1st Department of MedicineUniversity of Pavia

LES

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NORMAL ESOPHAGEAL MANOMETRY

1st Department of MedicineUniversity of Pavia

UES

LES

LES

Eso

phag

ealb

ody

UES

Stomach

LES

LES

Eso

phag

ealb

ody

DIFFUSE ESOPHAGEAL SPASM IN PARKINSON’S DISEASE

1st Department of MedicineUniversity of Pavia

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UES

Stomach

LES

LES

Eso

phag

ealb

ody

APERISTALSIS IN PARKINSON’S DISEASE

1st Department of MedicineUniversity of Pavia

Pharinx

NUTCRACKER ESOPHAGUS IN PARKINSON’S DISEASE

UES

Eso

phag

eal b

ody

Pharynx

1st Department of MedicineUniversity of Pavia

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UES

Stomach

LES

LES

Eso

phag

eal b

ody

1st Department of MedicineUniversity of Pavia

DILATED ESOPHAGUS IN PARKINSON’S DISEASE

ESOPHAGEAL MANOMETRY: INDICATIONS

1st Department of MedicineUniversity of Pavia

Evaluation of esophageal motility disorders

Determination of LES prior to pH-impedance studies

Pre-operatively to exclude esophageal motility diso rdersif antireflux surgery is considered

Dysphagia

- Primary esophageal motility disorders- Nonspecific esophageal motility disorders- Secondary esophageal motility disorders

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STATIONARY ESOPHAGEAL MANOMETRY AND UES

1st Department of MedicineUniversity of Pavia

“It is somewhat ironic that, althoughthe upper esophageal sphincter isthe most accessible structure of theesophagus, it is in many ways theleast well-understood .”

Ghosh SK, et al. AJP 2006

UES ESOPHAGEAL MANOMETRY - LIMITS -

UES pressure is influenced by recording methodology

Intraluminal catheters stimulate sphincter contraction

Contractile rate exceeds performance of perfused systems

UES presents an asymmetric structure

UES is characterized by axial movement during swallowing

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1st Department of MedicineUniversity of Pavia

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1st Department of MedicineUniversity of Pavia

LIMITS OF STATIONARY ESOPHAGEAL MANOMETRY:- PHARINGEAL ASYMMETRIC STRUCTURE -

Sears VW Jr, et al. Gastroenterology 1991

0

100

200

300

400

0 1 2 3 4 5 6

mm

Hg

cm above UES

anterior

posterior

right lateral

left lateral

Pharinx6 cm

above UES

Pharinx3 cm

above UES

UES

Anterior/posteriorCatheter orientation

90° rotated

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LIMITS OF STATIONARY ESOPHAGEAL MANOMETRY:- PHARINGEAL ASYMMETRIC STRUCTURE -

1st Department of MedicineUniversity of Pavia

anterior

posterior

right lateral

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HIGH RESOLUTION ESOPHAGEAL MANOMETRY

1st Department of MedicineUniversity of Pavia

1st Department of MedicineUniversity of Pavia

SOLID-STATE HIGH-RESOLUTION UES MANOMETRY

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SOLID-STATE HIGH-RESOLUTION MANOMETRY

1st Department of MedicineUniversity of Pavia

Assenza di peristalsi Onde simultaneea bassa pressione

Onde simultaneead elevata pressione

SOLID-STATE HIGH-RESOLUTION MANOMETRY

1st Department of MedicineUniversity of Pavia

Spasmo Esofageo Diffuso

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SOLID-STATE HIGH-RESOLUTION MANOMETRY

1st Department of MedicineUniversity of Pavia

Nutcracker esophagus Jackhammer esophagus

SOLID-STATE HIGH-RESOLUTION MANOMETRY

1st Department of MedicineUniversity of Pavia

Sclerodermic esophagus

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SOLID-STATE HIGH-RESOLUTION UES MANOMETRY

1st Department of MedicineUniversity of Pavia

Pharynx

CompleteSphincter Relaxation

IncompleteSphincter Relaxation

UES HIGH RESOLUTION MANOMETRY AND EMG

UESHRM

1st Department of MedicineUniversity of Pavia

Normal Relaxation Incomplete Relaxation

CFEMG

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1st Department of MedicineUniversity of Pavia

THE ADDED VALUE OF INTRALUMINAL IMPEDANCEIN THE STUDY OF DEGLUTITION

Non Acidic Reflux EpisodeP

roxi

mal

es

opha

gus

esophaguspH

IMP

ED

AN

CE

Dis

tal

esop

hagu

s

stomach

HIGH RESOLUTION IMPEDANCE MANOMETRY

1st Department of MedicineUniversity of Pavia

Pharynx

UES

LES

Eso

phag

eal

Bod

y

UES

Eso

phag

eal

Bod

y

LES

IntraluminalImpedance

IntraluminalPressure

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HIGH RESOLUTION IMPEDANCE MANOMETRY AND GERD

1st Department of MedicineUniversity of Pavia

Pharynx

UES

LES

Eso

phag

eal

Bod

y

UES

Bod

y

LES

HR IMPEDANCE MANOMETRY AND PHARYNGEAL TRANSIT

1st Department of MedicineUniversity of Pavia

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HR IMPEDANCE MANOMETRY AND PHARYNGEAL TRANSIT

1st Department of MedicineUniversity of Pavia

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