목차 - 삼성서울병원 · 내시경 관찰법 및 내시경 소견의 기술법...
Transcript of 목차 - 삼성서울병원 · 내시경 관찰법 및 내시경 소견의 기술법...
목차
내시경 관찰법 및 내시경 소견의 기술법 …………………………… 7
고위험군에서의 내시경 시행 및 내시경과 관련된 합병증의 관리 … 33
소화관 기능검사의 이해 …………………………………………… 55
2016 gastroenterology Winter School
Session 2. 위식도
내시경 관찰법 및
내시경 소견의 기술법
이 혁
2016 gastroenterology Winter School
내시경 관찰법 및 내시경 소견의 기술법
삼성서울병원 소화기내과
이 혁
삼성서울병원 2016 GI WINTER SCHOOL
2016 gastroenterology Winter School 7
Pictures to present
– Indicator of quality – At least 8 sections – Any abnormality detected.
Rey JF, et al. Endoscopy 2001
내시경 질 향상에서의 관찰과 기록
Armstrong, et al. CJG 2012
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Cardia
Courtesy of Prof. Jun Haeng Lee (EndoTODAY)
More than 40% of missed cancer
Blind areas
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Covered with endoscope
GC side of fundus
이준행. 제48회 대한소화기내시경학회 세미나
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Air insufflation is not everything
Courtesy of Prof. Jun Haeng Lee (EndoTODAY)
Covered with gastric rugae
Air insufflation
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Avoiding blind spots
Yao K. Ann Gastroenterol 2013
No safe location
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훈련을 통해서 마음속으로 코드화 하기
Emura, et al. Rev Gatroenterol Peru. 2013
E2, E3, A6, A7,
U19…….?!
Meticulous examination
Yao K. Ann Gastroenterol 2013
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Landmarks in upper endoscopy
Stomach – Cardia – Fundus in retroversion – Lesser curve and antrum overview – Distal extension of examination
3 important anatomical
narrowing
1. Upper esophageal sphincter
- 15-20cm from upper incisor
2. Anterior compression
- 20-25cm from upper incisor
3 Gastroesophageal junction
- 40-45cm from upper incisor
Landmarks in upper endoscopy
Esophagus
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Basic principles for endoscopic diagnosis of upper GI lesions
ESGE 2013
Gastro-esophageal junction
이준행. 대한소화기내시경학회지 2009
Landmarks in upper endoscopy
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“Red flag” techniques
Chromoendoscopy & Narrow-band imaging
Show sincerity in examination
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How to distinguish? Type I and IIa
Endoscopy 2005
How to measure the lesion?
Endoscopy 2005
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Report using Paris Classification
How to distinguish? Type IIc and III
Endoscopy 2005
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Validated or consensus classifications
Amstrong D, et al. Gastroenterology 1996
Los Angeles classification for reflux esophagitis
Benign vs. malignant ulcer
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Validated or consensus classifications
Zargar SA, et al. Gastroenterology. 1989
Zargar scale for corrosive injury
Validated or consensus classifications
Sharma P, et al. Gastroenterology 2006
Prague C & M classification for Barrett esophagus
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Validated or consensus classifications
Forrest classification for peptic ulcer bleeding
Forrest JA, et al. Lancet. 1974
Validated or consensus classifications Esophageal varices: Northern Italian Endoscopy Club and Conn scales
NIEC. N Engl J Med 1988
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Validated or consensus classifications Portal hypertensive gastropathy (Baveno classification)
de Franchis R. J Hepatol. 1996
Validated or consensus classifications
Sarin SK, Kumar A. Am J Gastroenterol. 1989
Gastric varices (Sarin and Kumar scale)
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Esophageal screening is much more important for patients with HNSCC
Prevalence of Second Primary ESCC Among Patients With HNSCC
JAMA OTOLARYNGOL HEAD NECK SURG 2013
Field cancerization
Pharynx or larynx is not other doctor’s business
40-60 cases in 1000 examinations
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How to report localized lesion
Cohen J, et al. Am J Gastroenterol 2006
Upper endoscopic reporting
• Normal findings
– Landmarks/extent of examination
– Quality of cleansing
– Quality of imaging/inspection
• Localized findings
– Features and location (and therapy)
• Diffuse findings
– Features and extent
ESGE 2013
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Photo-documentation Close-range and distant view
Retroflexion and forward-view
Photo-documentation
X
X
X
O
O X
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Photo-documentation • Focal lesion
– Overview of lesion and (if possible) nearby landmark – Overview with open biopsy forceps – Close-up showing surface/border/other defining
details – Color filter images as relevant – Post therapy result
• Diffuse lesion – Overview image with landmarks if possible/relevant – Detail of most affected area – Detail of typical lesions – Detail of demarcation line (if relevant)
Photo-documentation
6-month follow-up endoscopy
여러 가지 수단을 이용하여 병소를 강조
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ESD Surgery
Chromoendoscopy
Endoscopic biopsy
Ulcer base, margin, edge를 포함하여 4-6회 생검
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Take Home Message
• The endoscopic diagnosis of early gastric cancer is divided into three main steps: detection, characterization and reporting
• Use standardized language in endoscopic reports
- Standards for reporting endoscopy is a prerequisite for effective communication
• If a lesion is detected
- Describe all you would like others to tell you
• If applicable, use validated/consensus classifications
Training in upper endoscopy
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감사합니다
Training, training, training! ……to the grave….. Keep your original intention!
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고위험군에서의 내시경 시행 및
내시경과 관련된 합병증의 관리
박 정 호
2016 gastroenterology Winter School
• 고위험군에서의 내시경 검사
– 출혈의 위험성이 높은 환자
– 심폐질환 합병증의 위험성이 높은 환자
• 내시경과 관련된 합병증의 관리
– 출혈
– 천공
– 기타
목차
고위험군에서의 내시경 시행 및 내시경과 관련
된 합병증의 관리
성균관대학교 강북삼성병원 소화기내과 박정호
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Antithrombotic Drugs
고위험군에서의 내시경 검사– 출혈 위험성이 높은 환자
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Management of Antithrombotic Agents
Procedure Risk for Bleeding
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Best Practice Recommendation for the
Management of Dual Antiplatelet Therapy
Bridge Therapy for Wafarin
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고위험군에서의 내시경 검사– 심폐질환 합병증의 위험성이 높은 환자
• Systemic conditions
- Sepsis
- Shock
- Dehydration
• Cardiovascular conditions
- Arrhythmias
- Cardiac pacemaker
- Coronary artery disease
- History of myocardial ischemia
- Congestive heart failure
• Psychiatric conditions
- Uncooperative attitude
- Mental disorders
• Pulmonary dysfunction
- Chronic obstructive airways disease
- Interstitial lung disease
• Neurological conditions
- Seizure disorders
- History of stroke
• Gastrointestinal/hepatic conditions
- Active gastrointestinal bleeding
- Liver dysfunction
- Cirrhosis
• Genitourinary conditions
- Renal dysfunction
- Urinary retention
• Social conditions
- Elderly or young age
- Chronic use of prescribed sedatives
- Substance abuse
• History of drug allergy
• Pregnancy obesity
• History of radiation therapy
• Warfarin be restarted within 24 hours of the procedure in
patients with valvular heart disease and a low-risk for
thromboembolism.
• In patients at high risk for thromboembolism, UFH or
LMWH should be restarted as soon as “bleeding stability
allows”
Reinitiation of Antithrombotic Agents
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Effect of Endoscopy on CVS (I)
Automomic nervous system in CVS
Endoscopic procedure
parasympathetic↓ sympathetic↑
tachycardia, ischemia, arrythmia
Parasympathetic
bradicardiaslowing AV conduction
decrease atrial contractility
Sympathetic
HR ↑excitability ↑
CBF ↑
Safety of Current GI Endoscopy
• A retrospective cohort , 2000-2003, UK, 11051 patients
One patient death was caused directly by the EGD (1/9000)
McLernon DJ, et al. Endoscopy. 2007;39:692-700.
Maclernon et al. Endoscopy. 2007 Aug;39(8):692-700
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Safety and Efficacy of EGD after MI
Cappell MS, et al. Am J Med. 1999;106:29-35.Cena M et al. Cardiol J. 2012;19(5):447-52.
The complication rate was 1.5% (3 patients) in the control group and 7.5%
(15 patients) in the MI group :11 transient hypotension and 2 transient
hypoxia, 1 fatal ventricular tachycardia & 1 near respiratory arrest
A higher complication rate of 9% (9 patients) in the MI group vs. 1% (1
patient) in the control group: 7 transient hypotension, 1 transient bradycardia
& One major complication, death not believed to be related to the procedure
Effect of Endoscopy on CVS (II)
• Procedure related mechanical stress
- Esophageal irritation
- Gastric distension Sympathetic tone ↑
• Anxiety and neuroendocrine stress response
• Sedation and anagesia
- Opioid, midazolam, propofol
Hypoventilation, Parasympathetic tone ↑
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Respiratory Complications in Endoscopy
Cappell MS, et al. Am J Med. 1999;106:29-35.J Gastrointestin Liver Dis, September 2014;23(3): 255-259
Effect of Endoscopy on Lung Function
• Arterial O2 saturation ↓- Pretreatment
- Presence of the scope in the oropharynx
- Aspiration of gastric content
• Actually safe if pulmonary diseases are
controlled- O2 supply and saturation monitoring
- Less sedation
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Monitoring
• Preprocedural evaluation
- History, P/E, medication, drug allergies
- Cardiopulmonary status
- HR, BP, RR, SpO2
• Pulse oxymeter
• Continuous electrocardiogram
• Transcutaneous CO2 and end tidal CO2 monitoring
• Bispectral monitering
Major Complications related to Endoscopy
• Cardiopulmonary complication
• Complications related to sedation
• Bleeding
• Perforation
• Infectious complication
• Oral cavity injury
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수면마취??
Routine Use of Supplemental Oxygen
• Elderly Patients
- Relatively decreased baseline arterial oxygen saturation
- Blunted cardiovascular response to hypercarbia and hypoxia
- Exaggerated response to opioid-induced respiratory
depression
• Abnormal baseline oxygen saturation
• Severe cardiovascular disease
• Desaturation during the examination
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Bleeding
• 약 0.03%
• Mallory-Weiss 증후군 또는 조직검사에 의한 출혈
• 위험 인자
– 항응고제인 wafarin 등을 복용하고 있는 경우
– 간경화 환자, 혈액 투석 중인 환자
– 혈관 이상, 출혈의 기왕력이나 가족력이 있는 경우
진정(sedation)과 마취(anesthesia)의 레벨
경미한 진정Minimalsedation
(Anxiolysis)
중등도 진정Moderate sedation
(Conscious sedation)
깊은 진정Deep sedation
전신마취General
anesthesia
반응Responsiveness
말소리에 정상반응Normal response
to verbal stimulation
말소리나 가벼운자극에 반응
Purposeful response to verbal or tactile stimulation
반복적 혹은아픈 자극에 반응
Purposeful response after repeated or painful
stimulation
아픈 자극에도깨어나지 않음
Unarousable even with painful stimulus
기도Airway
영향을 받지 않음Unaffected
기도 확보 필요치 않음No intervention required
기도 확보 필요할 수 있음Intervention may be
required
기도 확보 필요함Intervention often
required
자발성 호흡Spontaneousventilation
영향을 받지 않음Unaffected
적절히 유지됨adequate
부적절할 수 있음May be inadequate
부적절함Frequently inadequate
심혈관 기능Cardiovascular
function
영향을 받지 않음Unaffected
대개 유지됨Usually maintained
대개 유지됨Usually maintained
영향을 받음May be required
.
ㅍ
ㅍ
ㅍ
ㅍ
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Bleeding by Biopsy
Mallory-Weiss syndrome
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Bleeding after CPP during Aspirin Therapy
Hematemesis 4 Hours after EMR
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Esophageal Perforation - Therapeutic
• Most frequently after esophageal dilatation
• Incidence: low (0.09 ~ 2.2%) for simple ring, stricture
• Mortality rate: 0 ~ 20%
Paspatis GA et al. Endoscopy. 2014; 46(8):693-711
Perforation – Diagnostic Endoscopy
• Incidence: 0.05 ~ 0.1%
• Mortality rate: 0.008%
• Diagnostic blind insertion
• Pharynx or upper esophagus
British Journal of Surgery 1995: 82(4) 530-533
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Retroperitoneal perforation during Diagnostic Colonoscopy
Colonic Perforation
• Incidence: 0.03 – 0.8% for diagnostic & up to 5% for
therapeutic endoscopy
• A risk of 1.1 % for colorectal perforation when polyps
were larger than 10mm in the right colon or 20mm in
left colon or when there were multiple polyps
• Post ESD: 20.4% → 1.9 ~ 4.7% (Japan)
Paspatis GA et al. Endoscopy. 2014; 46(8):693-711
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Risk Factors for Perforation
• 과도한 공기주입, 무리한 조직검사, 환자의 비협조
• 비만한 환자, 고령 환자, 기관내 삽관 상태의 환자
• 식도게실 (Zenker’s diverticula), 위저부 추벽형성술 (fundoplication)
• 척추후굴증 (kyphosis), 경추의 골관절염돌기 (osteoarthritic spurs)
• 문합부위, 협착부위 그리고 염증, 허혈, 종양 또는 부식제 등에 의하
여 점막벽이 약해져 있는 부위
Management of Colonic Perforation
Paspatis GA et al. Endoscopy. 2014; 46(8):693-711
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상부 내시경 관련 외인성 감염
Clin Microbiol Rev 26(2): 231-254
내시경적 감염 – 내인성 감염
• 낭성종양에서 EUS-FNA 후의 감염
률은 14% - fluoroquinolone 시술전,
후 3일간 예방적 투여
• 경피적 위루 삽입(PEG)전에 항생제
를 투여하면 피부 누공 주위의 감염
을 줄인다 – PEG 시술 30-60분 전
에 cefazolin
• 간경변증에서 위장관출혈이 있을때
예방적 항생제를 사용하면 감염률
과 사망률을 줄인다 – ceftriaxone
정맥 투여 또는 경구용 norfloxacin
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Superbug Transmission via Endoscopy
• NDM producing E. coli
• 2013년 3월 부터 7월까지 미국에서 9명
의 환자가 보고되었는데, 이들 중 8명이
northeastern Illinois에 위치해 있는 병원
에서 발생하였다.
• 높은 수준의 소독 후에도, NDM-
producing E. coli 와 K. pneumoniae 가
ERCP 내시경의 terminal section (the
elevator channel) 에서 발견되었다.
Morbidity and Mortality Weekly Report of CDC, 2014.1.3
하부 내시경 관련 외인성 감염
Clin Microbiol Rev 26(2): 231-254
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흡인 (Aspiration)
• Common status
- Advanced age, massive upper GI bleeding (1-4%)
- Altered mental status, absent gag reflex
- Unstable cardiopulmonary status
• Prevention
- Avoidance of topical anesthetics
- Prevention of oversedation
- Maintaining the head of the bed at a 30-40O angle
- Minimizing air insufflation
Other Complications
• 복부 팽만
• 이하선 또는 악하선의 종대
• 측두하악관절(temporomandibular joint)의 탈골
• 하부식도나 식도 열공 헤르니아에 내시경이 감돈
(impaction)되는 경우
• 급성 위점막 병변
• 결막하 출혈
• 폐암환자에서의 상대정맥 폐쇄
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소화관 기능검사의 이해
민 양 원
2016 gastroenterology Winter School
Testing of esophageal function
Upper endoscopy Barium radiography Esophageal manometry (+impedance) Ambulatory pH monitoring Advanced techniques
• Three-Dimensional high-resolution manometry• Impedance planimetry
Neurogastroenterol Motil 2013;25:99-133
식도 기능 검사의 이해
Yang Won Min, MD, PhD
Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
2016 삼성서울병원소화기내과윈터스쿨
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Esophagography
Upper endoscopy
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Esophageal manometry
1. Define esophageal motor function2. Delineate a treatment plan based on motor abnormalites
Gastroenterology 2005;128:207-224
Timed barium esophagogram (TBE)
J Neurogastroenterol Motil 2013;19:251-256
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Catheters
Conventional manometry
Neurogastroenterol Motil 2003;15:591
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A normal swallow in a Clouse plot
High resolution esophageal pressure topography
Neurogastroenterol Motil 2012;24 Suppl 1:2-4
High resolution manometry (HRM) Pressure topography plotting (Clouse plots)
Clouse plot
Peristalsis
Am
plit
ude
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Esophageal pressure topography (Clouse plot) - key landmarks used in the Chicago Classification
Clinical HRM Study
Series of ten test swallows of 5 ml water each in a supine posture
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Optimally distinguish normal from impaired EGJ relaxation Measurement
• Accurately localizing the margins of the EGJ• Demarcating the time window following deglutitive upper
sphincter relaxation within which to anticipate EGJ relaxation to occur
• Applying an e-sleeve measurement within that 10 s time box and then finding the 4 s during which the e-sleeve value was least (These 4 s are not necessarily continuous but can be scattered over the 10 s time window.)
The upper limit of normal for the IRP using the Given Imaging (Sierra) HRM assembly is 15 mmHg.
EPT-Specific Metrics II- the Integrated Relaxation Pressure (IRP) -
Pressure Topography MetricsMetric Description
Integrated relaxation pressure (mmHg)
Mean EGJ pressure measured with an electronic equivalent of a sleeve sensor for four contiguous or non-contiguous seconds of relaxation in the ten-second window following deglutitive UES relaxation
Distal contractile integral (mmHg-s-cm)
Amplitude x duration x length (mmHg-s-cm) of the distal esophageal contraction >20 mmHg from proximal (P) to distal (D) pressure troughs
Contractile deceleration point [(CDP) (time, position)]
The inflection point along the 30 mmHg isobaric contour where propagation velocity slows demarcating the tubular esophagus from the phrenic ampulla
Distal latency (s) Interval between UES relaxation and the CDP
All pressures referenced to atmospheric pressure except the IRP, which is referenced to gastric pressure
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Achalasia subtype
Type I Type II Type III
Calculate IRP
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PerOral Endoscopic Myotomy (POEM)
S/P POEM for Achalasia type III
TBE at 5 min TBE at 1 min
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Impedance planimetry- concept
Balloon is filled with conductive fluid
Impedance rings are evenly spaced throughout (17 rings in 8 cm)
Constant AC current Cross sectional diameter at
midpoint of each ring pair (total 16) can be measured based on impedance
Impedance planimetry- measures cross sectional area of the esophagus
in response to its distension
EndoFLIPTM
EndolumenalFunctional LumenImaging Probe
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Summarize the vigor of the distal esophageal contraction Measurement
• Segment spanning from the proximal to distal pressure trough (or to the EGJ)
• Conceptualized as the volume of the pressure from P to D • The first 20 mmHg is ignored.
The upper limit of normal defined by the 95th percentile in a normal population is 5000 mmHg-s-cm, whereas when defined as the value never encountered in a normal population it is 8000 mmHg-s-cm.
EPT-Specific Metrics III- the Distal Contractile Integral (DCI) -
Impedance planimetry- information obtained
Diameter between each ring pair
Cross-sectional area of balloon
Intraballoon pressure Distensibility can be
measured by measuring these data at different balloon volume
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Hypertensive peristalsis
Calculate DCI
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Jackhammer esophagus
DCI: 11156 mmHg-s-cm
Dysphagia and chest discomfort- M/58
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All pertain to the rate of contractile propagation in the distal esophagus.
• CDP, the transition from peristaltic propagation to the late phase of esophageal emptying
• CFV, measured for the segment preceding the CDP to be reflective of the peristaltic mechanism proper
• DL, measured from the time of upper sphincter relaxation to the CDP, again making it reflective of peristaltic timing and the period of deglutitive inhibition
EPT-Specific Metrics IVContractile Deceleration Point (CDP), Contractile Front Velocity (CFV)
and Distal Latency (DL)
S/P Diverculectomy with myotomy
Max DCI: 11156 7169 mmHg-s-cm
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Statement 1: GERD is defined as a disorder in which gastric contents reflux recurrently into the esophagus, causing troublesome symptoms and/or complications.
Statement 2: Typical symptoms of reflux are heartburn (retrosternal burning sensation) and acid regurgitation, which are commonly experienced by Asian patients.
Fock KM et al, J Gastroenterol Hepatol 2008;23:8-22
Vakil N et al, Am J Gastroenterol 2006;101:1900-1920
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PPI efficacy for potential manifestations of GERDEstimates based on available RCT data
Kahrilas PJ and Boeckxstaens G. Gut 2012;61:1501-1509
Persistent reflux symptoms on PPI therapy 19 primary care and community studies
El-Serag H et al, Aliment Pharmacol Ther 2010;32:720-737
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No 100% specific symptom of GERD
Persistent GERD symptoms may be related to Esophagitis of another etiology Severe dysmotility Rumination Functional heartburn Functional chest pain Insufficient acid suppression Weakly acidic reflux
Etiology of PPI failure
Compliance and adherence Residual acid, weakly acidic, and weakly
alkaline reflux Functional heartburn Psychological comorbidity, delayed gastric
emptying, eosinophilic esophagitis, and concomitant functional bowel disorder
Nocturnal acid breakthrough
Hershcovici T and Fass R. Dis Esophagus 2013;26:27-36
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Esophageal pH monitoring
Indications
1. Patients with typical GERD symptoms who fail 4 weeks of PPI therapy
2. Patients with atypical GERD symptoms who fail 6 to 8 weeks of PPI therapy
3. Patients being considered for endoscopic or surgical reflux therapy
4. Patients who have undergone endoscopic or surgical reflux therapy who continue to have GERD symptoms
Distinct phenotypes of incomplete PPI response to consider
GERD assessment tools
Esophageal pH monitoring Combined pH-impedance monitoring Manometry
Key questions:1. Do these patients have GERD?2. If they have GERD, what is the explanation for the lack
of response?
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pH parameters
1. Percentage of total time pH < 42. Percentage of supine time pH < 43. Percentage of upright time pH < 44. Total number of reflux episodes5. Number of reflux episodes > 5 minutes6. Duration of the longest reflux episode
pH < 4
• Pepsinogen is converted to its active form pepsin.• Heartburn often occur. • Normal subjects show pH ≥ 4 about 98.5% of the
time.
Esophageal pH monitoring
pH 전극(하부식도 괄약근상단의 5 cm 상방)
5 cm
15 cm
상부식도 괄약근
하부식도 괄약근
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Symptom indices
If a patient’s symptom is actually related to acid reflux episodes during pH monitoring.
1. Symptom index (SI)2. Symptom sensitivity index (SSI)3. Symptom association probability (SAP)
Sensitivity Specificity
SI 34.8% 80%
SSI 73.9% 73.3%
SAP 65.2% 73.3%
Normal values for 24h pH monitoring
Johnson/DeMeester1 Richter et al2
Percentage of total time pH < 4 < 4.2 < 5.78
Percentage of supine time pH < 4 < 1.2 < 3.45
Percentage of upright time pH < 4 < 6.3 < 8.15
Total number of reflux episodes < 50 < 46
Number of reflux episodes > 5 minutes ≤ 3 < 4
Duration of the longest reflux episode (min) < 9.2 < 18.45
1Johnson and Demeester. Am J Gastroenterol 1974;62:325-332 2Richter et al. Dig Dis Sci 1992;37:849-856
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Symptom association probability
• Probability (association between reflux and symptoms) calculated using the Fisher’s exact test
• SAP = (1-probability) x 100• Positive ≥ 95%
Positive SymptomPositive Reflux
Positive SymptomNegative Reflux
Negative SymptomPositive Reflux
Negative SymptomNegative Reflux
Symptom-reflux association analysis
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Principles of intraluminal impedancometry
Nguyen et al. Am J Gastroenterol. 1999;94:306-317
Combined impedance and pH
Acid vs nonacid reflux Persistent Sx on PPI
ComforTEC® Impedance-pH
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Bolus movement detected by MII
Antegrade bolus movement Retrograde bolus movement
Conchillo and Smout. Aliment Pharmacol Ther. 2008;29:3-14
Bolus movement waveform
baseline
air
contraction
50% baseline
Tutuian et al. Clin Gastroenterol Hepatol. 2003;1:174-182
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Recommended definitions for reflux
1. ‘‘Acid reflux’’ - refluxed gastric juice with a pH less than 4 which can either reduce the pH of the oesophagus to below 4 or occur when oesophagealpH is already below 4
2. ‘‘Superimposed acid reflux’’ - an acidic reflux episode that occurs before oesophageal pH has recovered to above 4
3. ‘‘Weakly acidic reflux’’ - reflux events that result in an oesophageal pH between 4 and 7
4. ‘‘Weakly alkaline reflux’’ - reflux episodes during which nadir oesophageal pH does not drop below 7
Sifrim et al. Gut 2004;53:1024-1031
Recording of Imp-pH monitoring
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Refractory GERD management
Kahrilas PJ, et al. Best Pract Res Clin Gastroenterol 2013;27:401-414
Subcategories of reflux
Sifrim et al. Gut 2004;53:1024-1031
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경과
2013.11 Pneumatic balloon dilatation 2013.12 잘 먹는다 (Eckardt score 9 3)
Manometry Esophagography
Final Diagnosis : Achalasia type II
Refractory GERD for 1 year, M/29
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F/59
• 목이 따갑다. 신물이 올라오고 가슴이 쓰리기도...
• 역류성식도염이라 듣고 두 달 약 복용했는데 효과 없다.
• 1년 전 외부 내시경에서 이상 없었다.
Refractory GERD
Kahrilas PJ, et al. Best Pract Res Clin Gastroenterol 2013;27:401-414
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24Hr Imp-pH monitoring, off PPI
Pathologic acid reflux and increased esophageal bolus exposure
EGD
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Insufficient acid suppression
• Esomeprazole 40mg 1T 1 회AM 60일
약 먹고 좋아짐. 역류가 덜하다.
pH 4
pain
Acidic reflux
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