27 Kathpalia Updates on Esophageal Disorders€¦ · [ADDPRESENTATIONTITLE:INSERTTAB>HEADER&$...

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5/25/171

Overview of Esophageal Disorders

Priya Kathpalia, MDUniversity of California, San FranciscoDivision of GastroenterologyMay 25, 2017

Objectives

§ Review anatomy of esophagus and define a “normal” swallow

§ Recognize classic symptoms of esophageal disorders

§ Discuss diagnosis and treatment of eosinophilic esophagitis

§ Know the differential for esophageal eosinophilia

§ Evaluate the procedure, indications for esophageal manometry

§ Analyze the Chicago Classification System

§ Understand clinical applications of high-resolution manometry

2

Anatomy of Esophagus and Normal Swallow Patterns

3

Anatomy of Esophagus

4

Upper EsophagealSphincter (UES)

Lower EsophagealSphincter (LES)

Esophageal Body(cervical & thoracic)

àContracts during inspirationàRelaxes during swallowing

àMaintains steady baseline toneàPrevents gastric contents from entering esophagusàContracts when increased intra-abdominal pressure


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5

Muscularis has 2 layers:

à Inner circular muscle contracts

àOuter longitudinal muscle shortens the esophagus


6

Defining ‘Normal’ Swallow Patterns

7

Defining ‘Normal’ Swallow Patterns

8

§ Complex processes

• Consists of parasympathetic and sympathetic nerves

§ Peristalsis controlled by:

• Parasympathetic pathway

• Enteric nervous system

Pandolfino J, Gawron A. JAMA 2015. 313 (18): 1841-1852.


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Typical Symptoms of Esophageal Disorders

9

Esophageal Disorders: Classic Symptoms

Perception Related:

• Heartburn/reflux

• Dry cough/sore throat

• Globus sensation

• Chest pain/pressure

10

Transit Related:

• Regurgitation

• Dysphagia

• Odynophagia

• Food impaction

Approach to Heartburn/Reflux

11 Kahrilas P, et al. Am J Gastroenterol 2010;; 105:757-756.

Eosinophilic Esophagitis (EoE)

12


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EoE: Background

§ First cases described in 1970s in children, 1990s in adults

§GERD with eosinophilia described first in 1982

§ Prevalence 0.44% in US, as high as 10-15% if dysphagia

§Male predominance (3:1), generally in 3rd or 4th decade

§Often patients have personal and/or family history of atopy

13 Blanchard C, et al. J Clin Invest 2006;; 115:536-547.

EoE: Symptoms

14 Dellon E, et al. Am J Gastroenterol. Oct 2009. Vol 104(3):S24.

EoE: Clinicopathologic Diagnosis

§ Clinically, symptoms related to esophageal dysfunction

§ Pathologically, eosinophil predominant inflammation on esophageal biopsies (>15 eos/hpf)

§Other etiologies of eosinophilia excluded, including PPI-responsive esophageal eosinophilia

§ Dietary exclusion or topical corticosteroids should allow for dissipation of symptoms

15 Blanchard C, et al. J Clin Invest 2006;; 115:536-547.Dellon E, et al. Am J Gastroenterol 2013;; 018:679-692.

EoE: Endoscopic Findings

16 Lucendo A, et al. Gastrointestinal Endoscopy (book), Chapter 6, 2011. Pg 63-78.


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EoE: Treatment Options

§Medical or dietary therapy can often lead to resolution of symptoms

§ Treatment:

• PPI

• Topical (swallowed) steroids

• 6-food elimination diet (wheat/egg/soy/milk/peanuts/seafood)

• Dilation

§ Allergy evaluation not helpful

17 Dellon E, et al. Am J Gastroenterol 2013;; 018:679-692.

Differential Diagnosis for Esophageal Eosinophilia

18

Other Etiologies for Esophageal Eosinophilia§ Usually esophagus devoid of eosinophils


Differentiating GERD from EoE



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Approach to Heartburn/Reflux

21 Kahrilas P, et al. Am J Gastroenterol 2010;; 105:757-756.

Esophageal Manometry: Equipment and Procedure

22

Esophageal Manometry: Equipment

§ First invented in 1950s

§ Newer catheters developed in late 1990s

§ Newer catheters have:

• Improved sphincter localization

• Reduced artifact from patient movement

• Minimal need for calibration

• Lower maintenance

23

Esophageal Manometry: Equipment

§ Solid state catheter from pharynx to the stomach

• 36 sensors placed 1 cm apart

24


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Esophageal Manometry: Understanding Indications

25

Esophageal Manometry: Indications

§ For esophageal motility disorders, in particular achalasia

§ In patients with heartburn or dysphagia who have normal EGD

§ In patients with non-cardiac chest pain

§ Pre-op evaluation for fundoplication

§ Post-fundoplication if persistently symptomatic

26

Chicago Classification System

27

Esophageal Manometry: Chicago Classification v.3

28

§Official classification system for esophageal pressure topography

§ Initially published in 2008, has since been modified in 2012 / 2015

Kahrilas P, Ghosh S, Pandolfino J. J Clin Gastroenterol 2008. 42:627-635.Bredenoord A, Fox M, Kahrilas P, et al. Neurogastroenterol Motil 2012. 24:57-65.


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Pandolfino J, Gawron A. JAMA 2015. 313 (18): 1841-1852.

30

31

Esophageal Manometry: Defining the Landmarks – Integrated Relaxation Pressure (IRP)

Normal IRP < 15 mmHg 32

Esophageal Manometry: Defining the Landmarks – Contractile Deceleration Point (CDP)


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33

Esophageal Manometry: Defining the Landmarks – Distal Latency (DL)

Normal DL ≥4.5 secReduced DL <4.5 sec

34

Esophageal Manometry: Defining the Landmarks – Distal Contractile Integral (DCI)

Hypercontractile swallow DCI >8000 mmHg·cm·secWeak swallow DCI <450 mmHg·cm·secFailed swallow DCI <100 mmHg·cm·sec

35 Kahrilas P, Bredenoord A, Fox M, et al. Neurogastroenterol Motil 2015. 27:160-174.

Clinical Applications

36


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Case Discussion #1

§ 65 y/o female with history of hypertension, hyperlipidemia

• Presents with 6 months of episodic vomiting, dysphagia

• Difficulty swallowing initially with solids now to solids and liquids

• Also has atypical chest pain

• Has lost 15 lbs in the past 3 months

• Denies alcohol or tobacco use

37

Barium Esophagram Findings

38

Upper Endoscopy Findings

39

Esophageal Manometry Findings

40IRP = 20 mmHgNormal IRP < 15 mmHg


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41 Carlson D, Pandolfino J. Gastroenterology & Hepatology 2015. 11(6): 374-384.

Achalasia: Overview

§ Derived from Greek word ‘khalasis’ – not loosening or relaxing

§ Incidence: 1/100,000 worldwide

§ Associated with loss of myenteric plexus ganglion cells in distal esophagus and LES

§ Various theories

• Autoimmune process triggered by an indolent viral infection in a genetically susceptible host

• Also one manifestation of Chagas disease;; parasite Trypanosoma cruzi

42 Kraichely R, Farrugia G, Pittock S, et al. Dig Dis Sci 2010. 55(2):307-311.De Oliveira R, Rezende F, Dantas R, et al. Am J Gastroenterol 1995. 90(7):1119-1124.

Achalasia: Symptoms

43 Pandolfino J, Gawron A. JAMA 2015. 313 (18): 1841-1852.

Achalasia: Diagnosis §Combination of testing to come to diagnosis:

1) Esophagram

2) Upper endoscopy

3) Esophageal manometry

44


5/25/1712

Achalasia: TreatmentTreatment aimed at reducing LES pressure, increasing emptying

Return of peristalsis highly unlikely

1) Heller Myotomy. POEM?

‒ Lasts 5-10 years

2) Pneumatic Balloon Dilation

‒ Lasts 2-5 years

3) Botulinum Toxin

‒ Lasts 6-12 months

4) Nitrates, calcium channel blockers

‒ Variable response

45 Pasricha P, Rai R, Ravich W, et al. Gastroenterology 1996. 110(5):1410-1415.Boeckxstaens G, Annese V, des Verannes S, et al. N Engl J Med 2011. 364(19):1807-1816.

Case Discussion #2

§ 65 y/o female with history of hypertension, hyperlipidemia

• Presents with 6 months of episodic vomiting, dysphagia

• Difficulty swallowing initially with solids now to solids and liquids

• Also has atypical chest pain

• Has lost 15 lbs in the past 3 months

• Denies alcohol or tobacco use

46

Barium Esophagram Findings

47

Upper Endoscopy Findings

48 Park J. J Neurogastroenterol Motil 2010. 16(4):442-443.


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49IRP = 20 mmHgNormal IRP < 15 mmHg


50 Carlson D, Pandolfino J. Gastroenterology & Hepatology 2015. 11(6): 374-384.

Subsequent CT Findings

51

EGJ Outflow Obstruction: Differential

§ Early achalasia

§ Pseudoachalasia

§ Strictures/rings

§ Paraesophageal hernia

§ Infiltrative process

§ External compression

52


5/25/1714

Take Home PointsØSwallowing is complex, entails a combination of voluntary and involuntary reflexes

ØPredominant symptoms involved in esophageal disorders can be due to perception or transit dysfunction

ØEosinophilic esophagitis requires clinical symptoms with pathologic diagnosis (>15 eos/hpf on esophageal biopsies)

Ø6-food elimination diet as effective as medications in treating EoE

ØRecognize that GERD is in the differential for esophageal eosinophilia

53

Take Home Points

ØPatients with classic achalasia have aperistalsis and poor LES relaxation

ØUse combination of radiologic, endoscopic, and manometric studies to make diagnosis

ØVarious treatment options for achalasia though Heller myotomy or pneumatic dilation have longest durable response

ØPatients with EGJOO have poor LES relaxation but normal peristalsis

ØConsider CT scan or EUS in elderly patients with EGJOO

54

Thank you!

Division of Gastroenterology Center for Gastrointestinal Motility 1701 Divisadero St., Suite 120Phone: (415) 502-4444Email: [email protected]

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