esophageal motility disorders - american college of...
TRANSCRIPT
![Page 1: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/1.jpg)
Peter J. Kahrilas, MD, FACG
Esophageal Motility DisordersCurrent classification and treatment
Peter J. Kahrilas, M.D.Peter J. Kahrilas, M.D.,,Northwestern Northwestern UniversityUniversityChicago, USAChicago, USA
Bredenoord AJ et al, Neurogastroenterol Motil 2012;24(suppl 1):57-65EMD #68 v5/15/13 PJK
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
1
![Page 2: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/2.jpg)
Peter J. Kahrilas, MD, FACG
Normal Esophageal MotilityPressure topography plot with key metrics
Swallow
P
DCDPLatency
DL>4 5s
Distal contractile IntegralDCI<8,000 mmHg-s-cm
EPT #35 v7/10/13 PJK
DDL>4.5s
IRP windowIRP<15 mmHg
Interpreting Clinical EPT StudiesThe tools of analysis
• IRP (Integrated Relaxation Pressure)– The best validated metric of deglutitive relaxationThe best validated metric of deglutitive relaxation– Advantages of a sleeve-type recording– Accounts for both nadir and persistence of relaxation
CCL #10a v4-18-10 PJK
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
2
![Page 3: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/3.jpg)
Peter J. Kahrilas, MD, FACG
hagu
s (c
m)
0
5
10
EGJ relaxation (IRP calculation)
Leng
th a
long
the
esop
h
15
20
25
30
2 s
EGJ
eSleevedomain
0
30
015
eSleevePressureIntra-gastricPressure
35
1.6 mmHg
CCL #13 v4-30-12 PJK
IRP = mean of red fill
Deglutitive EGJ Relaxation MeasuresSensitivity in detecting achalasia
False -Achalasia sensitivity ( 2)EGJ relaxation measure False (n=62)EGJ relaxation measure
3%97%4s Integrated Relaxation Pressure (<15 mmHg )
31%69%High resolution nadir
(<10 mmHg)
48%52%Single sensor nadir
(<7 mmHg )
EPT #8 v1/29/11 PJK
Pressure (<15 mmHg )
Ghosh SK et al. Am J Physiol 2007;293:G878
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
3
![Page 4: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/4.jpg)
Peter J. Kahrilas, MD, FACG
Fitting Chicago Classification to EPT StudiesHierarchical analysis
Probably AchalasiaIRP ≥15 mmHg & absent peristalsis
Yes Achalasiao Type I: classic o Type II: with esophageal compression 1o Type III: spastic
CCL #11 v1-25-11 PJK
Achalasia Subtypes
100
150
mmHg
Type I (classic)
h l
0
5
10
15
20
cm
30 mmHgPanesophageal pressurization Type II
(achalasia i h
50
0
30
achalasia
IRP= 22.3 mmHg
5 s
30 mmHg IBC25
30
35
IRP= 28.9 mmHg5 s
with compression)
30 mmHg IBC
SPV plot
300 mmHg0
5
1030 mmHg
SPV plot
150 mmHg
Kahrilas PJ et al, Gastroenterology 2013;In PressEMD #69 v7/9/13 PJK
Type III (spastic) achalasia
IRP= 52.3 mmHg5 s
Distal latency =
2.5 s
15
20
25
30
35
IRP= 28 mmHg5 s
Compartmentalized pressurization
30 mmHg IBC ‘type IV’
EGJ outflow
obstruction
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
4
![Page 5: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/5.jpg)
Peter J. Kahrilas, MD, FACG
Achalasia treatment outcome by EPT subtypeType I (classic), Type II (pressurization), Type III (spastic)
Publication N, (Rx type) Type I Type II Type IIIPercent with ‘good’ outcome
Publication N, (Rx type) Type I Type II Type IIIPandolfino 2008 [1] 99
(PD, LHM, Botox)56%
(n=21)96%
(n=49)29%
(n=29)
Salvador 2010 [2] 246(LHM)
85%(n=96)
95%(n=127)
69%(n=23)
Pratap 2011 [3] 51(PD)
63%(n=24)
90%(n=24)
33%(n=3)
Rohof 2013 [4] 176 86% (PD) 100% (PD) 40% (PD)Rohof 2013 [4] 176(RCT: PD, LHM)
86% (PD)81% (LHM)
(n=44)
100% (PD)95% (LHM)
(n=114)
40% (PD)86% (LHM)
(n=18)
EMD #61 v3/19/13 PJK
[1] Pandolfino JE, et al Gastroenterology 2008;135:1526[2] Salvador R, et al J Gastrointest Surg 2010;14:1635
[3] Pratap N, et al Neurogastroenterol Mot 2011;17:205[4] Rohof W, et al Gastroenterology; epub ahead of print
150
mmHg0
5
Pre-myotomy
UES
Pre and Post-treatment esophageal pressure topography in achalasia
Post-myotomy
100
50
30
5
10
15
20
25
30
Length along the
esophagus (cm)
UES
EGJ
Pan-esophageal pressurization
Peristaltic remnant
Proximal break
Distal break
035
5 s
EMD #57 v3/31/13 PJK Roman S, et al. JAMA Surg 2013;148(2):157-64
Type II achalasia
5 s
Weak peristalsis
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
5
![Page 6: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/6.jpg)
Peter J. Kahrilas, MD, FACG
UES 150
mmHg0
5
Pre-myotomy
Pre and Post-treatment esophageal pressure topography in achalasia
Post-myotomy
UES
100
50
30
5
10
15
20
25
30
Length along the
esophagus (cm)
EGJ
Peristaltic remnant
Proximal break
Distal break
Pan-esophageal pressurization
Early latency (spastic)
contraction
DL= 2.1 s
035
5 s
EMD #58 v3/31/13 PJK Roman S, et al. JAMA Surg 2013;148(2):157-64
Type III (spastic) achalasia
5 s
Distal esophageal spasm
Pre and Post-treatment esophageal pressure topography in achalasia
Post-treatment pattern
EGJ outflow obstruction
Type I achalasia
4
6
8
10
12
14
16
82
5
2
1
1
1
2
2
Number of
patients
Type I achalasia
Premature contraction
Frequent failed peristalsis
Weak peristalsis
Absent peristalsis
0
2
Type 1 Type 2 Type 3
3111
Pre-treatment achalasia subtype
EMD #59 v3/31/13 PJK Roman S, et al. JAMA Surg 2013;148(2):157-64
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
6
![Page 7: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/7.jpg)
Peter J. Kahrilas, MD, FACG
Evolution of achalasia over a 2-year period, Myenteric plexus inflammation at LES
2006 2007 2008
EMD #60 v12/10/12 PJK
Finally treated with laparoscopic Heller myotomy
Evolution of achalasia over a 2-year period, Myenteric plexus inflammation at LES
2006 2007 2008
Intact Peristalsis
Weak Peristalsis
Type II Achalasia
EMD #60 v12/10/12 PJK
Finally treated with laparoscopic Heller myotomy
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
7
![Page 8: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/8.jpg)
Peter J. Kahrilas, MD, FACG
Achalasia TreatmentsGeneral principles
• Early treatment is desirable– Prevents disease progression and complications
• Dysphagia responds to Rx better than chest painDysphagia responds to Rx better than chest pain• Botox can be a useful temporizing measure
– Doubt in diagnosis– Elderly, frail patient
• Pneumatic dilation and LHM are both highly effective and highly operator dependent procedures– Leverage regional expertise
EMD #12 v4/4/11 PJK
– Comparative data from the literature are not necessarily locally or even regionally applicable
• Peroral Endoscopic Myotomy (POEM) is a promising new technique
Botox®Know when to say, “when”
EMD #29 v7/5/10 PJK
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
8
![Page 9: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/9.jpg)
Peter J. Kahrilas, MD, FACG
Pneumatic Dilators used for Treating Achalasia
Microvasive® Rigiflex Dilator (3.0, 3.5, or 4.0 cm)
EMD #8 v12/10/12 PJK
g ( , , )Passed over guidewire, imaged with fluoroscopy
Microvasive™ Pneumatic Dilation35 mm dilator
EMD #9a v2/20/10 PJK
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
9
![Page 10: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/10.jpg)
Peter J. Kahrilas, MD, FACG
Microvasive™ Pneumatic Dilation35 mm dilator
“W i ” l i“Waist” locating the LES
EMD #9b v2/20/10 PJK
Microvasive™ Pneumatic Dilation35 mm dilator
Eff t fEffacement of “Waist”
EMD #9c v2/20/10 PJK
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
10
![Page 11: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/11.jpg)
Peter J. Kahrilas, MD, FACG
Achalasia TreatmentsPneumatic dilation
• 1% perforation risk
DisadvantagesAdvantages
• Outpatient procedurerequiring surgical repair
• Less efficacious than myotomy
• Less predictable than myotomyM d 2 3
p p• Can repeat• Can be long-term
solution• Halts disease
progression
EMD #11c v12/10/12 PJK
• May need 2 or even 3 successive dilations
progression• Rare post-Rx reflux
Mucosa throughMucosa throughmyotomymyotomy
Laparoscopic Heller Myotomy with DorFundoplication
EsophagusEsophagus
EMD #10 v2/20/10 PJKPeters & DeMeester
Minimally Invasive Surgery of the Foregut 1994
Right crus ofRight crus ofdiaphragmdiaphragm
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
11
![Page 12: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/12.jpg)
Peter J. Kahrilas, MD, FACG
Achalasia TreatmentsLaparoscopic Heller myotomy
• Usually requires
DisadvantagesAdvantages
• The most effective hospitalization
• 1% perforation risk requiring intervention
• Operative morbidity and mortality
• Expensive
treatment• The most definitive
treatment• Halts disease
progression
EMD #11d v12/10/12 PJK
p• Post-Rx reflux in > 50%
p g
Success rates of pneumatic dilation and laparoscopic Heller myotomy
The European Achalasia Trial, 2 year results
Heller myotomy (n=97)
Pneumatic dilation (n=78)
Successful treatment (%) 97% 78%
Eckardt score 1.1 ± 0.1 1.3 ± 0.1
LES pressure (mmHg) 14 ± 1 12 ± 1
Timed barium swallow (cm) 3.4 ± 0.6 4.8 ± 0.7
Boeckxstaens GE, et al. NEJM 2011:364:1807-1816EMD #43 v1/25/11 PJK
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
12
![Page 13: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/13.jpg)
Peter J. Kahrilas, MD, FACG
Complication rates of pneumatic dilation and laparoscopic Heller myotomy for achalasia
Northwestern experience 2000-2011 (n=463 patients)
Lynch KL et al. Am J Gastroenterol 2012;107:1817-25EMD #42 v9/18/12 PJK
Relationship between series size and perforation rate for (modern) pneumatic dilation in achalasia
Funnel plot
U d ll 35 dil ti
Number of patients in series (n)
100
200
300
400
Northwestern experience
Used all 35 mm dilations
European Achalasia trial
With the first
Procedural esophageal perforations (%)
0
EMD #55 v1/25/13 PJK Lynch KL et al. Am J Gastroenterol 2012;107:1817-25
0 1 2 3 4 5 6
With the first 13 cases (7.2%)
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
13
![Page 14: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/14.jpg)
Peter J. Kahrilas, MD, FACG
Per-Oral Esophagomyotomy (POEM)Novel alternative to LHM or PD for achalasia
……laparoscopic Heller-Dor myotomy still requires 5 abdominal skin incisions for trocar placement. Pasricha initially reported a method of submucosal endoscopic myotomy with no skin incision in an experimental model [1]. Subsequently, Inoue modified the technique and applied it clinically…[2].
1. Pasricha, et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 2007;39(9):761-4.
2. Inoue H, et al. First clinical experience of submucosal endoscopic myotomy foresophageal achalasia with no skin incision. Gastrointest Endosc 2009;69:A122
EMD #34 v7/21/10 PJK
POEM (1) Enter into the submucosa in the mid esophagus
mucosal layer
View through transparent distal cap on endoscope
Triangle tip knife
EMD #35a v7/21/10 PJK Courtesy of H. Inoue
endoscope
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
14
![Page 15: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/15.jpg)
Peter J. Kahrilas, MD, FACG
POEM (2) Creation of submucosaltunnel ≈ half esophageal circumference
palisade vessels
mucosal layer
EMD #35b v7/21/10 PJK Courtesy of H. Inoue
POEM (3) Myotomy begun ≈ 3 cm distal to entry, ≈ 7 cm above EGJ
EMD #35c v7/21/10 PJK Courtesy of H. Inoue
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
15
![Page 16: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/16.jpg)
Peter J. Kahrilas, MD, FACG
POEM (3) Myotomy completion
EMD #35d v7/21/10 PJK Courtesy of H. Inoue
POEM (4) Clipping
EMD #35e v7/21/10 PJK Courtesy of H. Inoue
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
16
![Page 17: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/17.jpg)
Peter J. Kahrilas, MD, FACG
Achalasia TreatmentsPer-Oral Endoscopic Myotomy (POEM)
• New
DisadvantagesAdvantages
• Incisionless (NOTES)• Learning curve situation • Limited data on
morbidity, mortality, post-op reflux
• Long term?
( )• Surgical efficacy
without surgical morbidity
• (Should) halt disease progression
EMD #11d v12/10/12 PJK
Long term?p g• Potential to ‘customize’
Fitting Chicago Classification to EPT StudiesHierarchical analysis
Probably AchalasiaIRP ≥15 mmHg & absent peristalsis
Yes1
o Type I achalasia: classic o Type II achalasia: with esophageal
compression o Type III achalasia: (includes spastic)
Major motor disorderIRP ≥15 mmHg OR absent peristalsis OR reduced latency OR DCI >8,000
mmHg-s-cm
No, but…
2
CCL #11 v11-14-11 PJK
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
17
![Page 18: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/18.jpg)
Peter J. Kahrilas, MD, FACG
Fitting Chicago Classification to EPT StudiesHierarchical analysis
Probably AchalasiaIRP ≥15 mmHg & absent peristalsis
Yes1
o Type I achalasia: classic o Type II achalasia: with esophageal
compression o Type III achalasia: (includes spastic)
Major motor disorderIRP ≥15 mmHg OR absent peristalsis OR reduced latency OR DCI >8,000
mmHg-s-cm
No, but…
2
Absent peristalsisDistal esophageal spasmo Pseudorelaxation?o Spastic achalasia with low LESP?EGJ outflow obstructiono may be an achalasia variant Hypercontractile (Jackhammer)
esophagus
Yes
CCL #11 v11-14-11 PJK
esophagus
Latency vs contraction velocity as criterion for DESLatency is a much more specific abnormality
mmHg
0
0.2
Normalized length
along the esophagus
CDP
2
0.4
0.6
0.8 CDP
Distal contraction latency
50th and 95th percentile of normal
for latency
CDP
Propagation velocity = 15 cm/sDistal contraction latency (DL) = 7.0 s
EPT #30 4/4/11 PJK Roman S, et al. Am J Gastroenterol 2011;106:443
8
10 5 10 15 20
Time (s)
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
18
![Page 19: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/19.jpg)
Peter J. Kahrilas, MD, FACG
Phenotypes of rapid propagationRefining the diagnosis of DES
Rapid Contraction Weak Contraction
0150
100
5015 cm/s
3 cm/s 1
cm/s
27.0 s
15 cm/s
5.9 s
0
5
10
15
20
25
5.5 cm5.5 cm
-25 cm/s
EPT #32 v1/30/12 PJK
mmHg
02 cm/s 0.5
cm/s
7.0 s
2 s
Time (s)
0.5 cm/s 2 s
Time (s)
30
35
Pandolfino JE, et al. Gastroenterology 2011;141:469
Latency vs contraction velocity as criterion for DESLatency is a much more specific abnormality
mmHg
0
00.2
0.4
0.6
0
Normalized length
along the esophagus
50th and 95th percentile of normal
for latency
Distal contraction latency
0 5 10 15 20
0.8
1
Propagation velocity = 25 cm/sDistal contraction latency (DL) = 3.0 s
EPT #29 4/4/11 PJK Roman S, et al. Am J Gastroenterol 2011;106:443
CDP
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
19
![Page 20: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/20.jpg)
Peter J. Kahrilas, MD, FACG
1070 consecutive patients with clinical EPT studies
91 Patients with rapid propagation
Premature Contractions (n=24)[Distal latency < 4.5 s]
Rapid Contractions (n=67)[CFV > 9 cm/s / normal latency]
6
18 39
27
4
14
Spastic achalasiaDES
18 4
Weak peristalsis – segmental contractionFunctional EGJ obstructionWeak peristalsisHypertensive peristalsisNormal
EPT #31 1/25/11 PJK
Jackhammer esophagus (DCI>8,000 mmHg-s-cm)Repetitive contractions not synchronized with respiration
0
5cm)
mmHg
100
50
200
20
DCI = 12,957 mmHg-s-cm
5
10
15
20
25ong
the
esop
hagu
s (c
150
0
mmHg
020
Time (s)
25
30
35
Leng
th a
lo
0 10 20 30
EPT #35 v1/30/12 PJK Roman S, et al. Am J Gastroenterol 2012;107:37
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
20
![Page 21: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/21.jpg)
Peter J. Kahrilas, MD, FACG
Phosphodiesterase type 5 inhibitors for EMDBackground
• Sildenafil potentiates the activity of endogenous NO by inhibiting an enzyme (PDE type V) that catalyzesby inhibiting an enzyme (PDE-type V) that catalyzes the second messenger (cGMP) mediating NO action
• Reduces esophageal contractile amplitude for several hours
• Less consistent effect on peristaltic propagationP i ll f l f EMD i h h ili• Potentially useful for EMD with hypercontractility
EMD #37 v7/21/10 PJK
Rhee PL, et al. Am J Gastroenterol 2001;96:3251-7Bortolotti M, et al. Dig Dis Sci 2001;46:2301-6
Eherer AJ, et al. Gut 2002;50:758-64Lee JI, et al. Neurogastroenterol Motil 2003;15:617-23
Agrawal A, et al. Dig Dis Sci 2005;50:2059-62
Phosphodiesterase type 5 inhibitors for EMDCase reports with EPT
45 minutes post-sildenafil 25 mg
Fox M, et al. Neurogastroenterol Motil 2007;19:798-803
Pre-sildenafilSevere swallow-related chest pain
50 minutes post-sildenafil, solid challenge
EMD #38 v7/21/10 PJK
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
21
![Page 22: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/22.jpg)
Peter J. Kahrilas, MD, FACG
Phosphodiesterase type 5 inhibitors for EMDCase reports with EPT
Fox M, et al. Neurogastroenterol Motil 2007;19:798-803
Pre-sildenafilSevere dysphagia and chest pain
Solid swallow challenge
EMD #39 v7/21/10 PJK
45 minutes post-sildenafil 25 mgReduced dysphagia, no chest pain
Fitting Chicago Classification to EPT StudiesHierarchical analysis
Probably AchalasiaIRP ≥15 mmHg & absent peristalsis
Yes1
o Type I achalasia: classic o Type II achalasia: with esophageal
compression o Type III achalasia: (includes spastic)
Major motor disorderIRP ≥15 mmHg OR absent peristalsis OR reduced latency OR DCI >8,000
mmHg-s-cm
No, but…
2
Absent peristalsisDistal esophageal spasmo Pseudorelaxation?o Spastic achalasia with low LESP?EGJ outflow obstructiono may be an achalasia variant Hypercontractile (Jackhammer)
esophagus
Yes
CCL #11 v11-14-11 PJK
Not major motor disorderBut… Peristaltic abnormalities
No
3
esophagus
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
22
![Page 23: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/23.jpg)
Peter J. Kahrilas, MD, FACG
Fitting Chicago Classification to EPT StudiesHierarchical analysis
Probably AchalasiaIRP ≥15 mmHg & absent peristalsis
Yes1
o Type I achalasia: classic o Type II achalasia: with esophageal
compression o Type III achalasia: (includes spastic)
Major motor disorderIRP ≥15 mmHg OR absent peristalsis OR reduced latency OR DCI >8,000
mmHg-s-cm
No, but…
2
Absent peristalsisDistal esophageal spasmo Pseudorelaxation?o Spastic achalasia with low LESP?EGJ outflow obstructiono may be an achalasia variant Hypercontractile (Jackhammer)
esophagus
Yes
CCL #11 v3-2-12 PJK
esophagus
Not major motor disorderBut… Peristaltic abnormalities
No
3
No
Weak peristalsiso with large or small 20 mmHg
isobaric contour breaksFrequent failed peristalsisHypertensive peristalsis
(nutcracker esophagus)Rapid contraction
Normal
Yes
Esophageal Motility: Impact of HRM/EPTCirca 2013
• EPT has clarified the diagnosis of achalasia and defined criteria for EGJ outflow obstruction as a distinct diagnosis
• Spasm remains difficult, but EPT may sort out subsets of reduced-latency and hypercontractileconditions amenable to specific therapies
• EPT findings should be prioritized: 1) impaired EGJ relaxation, 2) reduced latency contractions, 3) extreme hypo- or hypercontractility, 4) then….
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
23
![Page 24: Esophageal Motility Disorders - American College of ...s3.gi.org/wp-content/uploads/2013/09/13ACG_Williamsburg_Regional... · Author: tbongorno Subject: ACG 2013 Regional Postgraduate](https://reader030.vdocuments.us/reader030/viewer/2022013014/5aa80b387f8b9ac5258b559e/html5/thumbnails/24.jpg)
Peter J. Kahrilas, MD, FACG
Esophageal Motor Disorders, What’s New?Treatment
• POEM (per-oral endoscopic myotomy) is potentially superior to existing achalasia treatmentssuperior to existing achalasia treatments
• Phosphodiesterase-type 5 inhibitors are potentially useful to treat hypercontractile EMD
EMD #40 v7/10/13 PJK
ACG Regional Postgraduate Course - Williamsburg, VA Copyright 2013 American College of Gastroenterology
24