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High Resolution Manometry ccv 4.0 on Esophageal motility disorders.pptx
- 1. Esophageal motility disorderson High Resolution Manometry: Chicago Classification v4.0 Dr. Ajay Kumar Yadav DM resident Gastroenterology, NAMS 2081/07/14
- 2. Layout Esophageal anatomy andphysiology High Resolution Manometry (HRM) Chicago Classification Version 4.0 (CCv4.) • Evolution • Principles and Updates • Preparation and Positioning • HRM Metrics and Thresholds • Provocative measures • CCv3.0 Vs CCv4.0 • Diagnosis of Esophageal motility and obstructive diosrders • Take Home message
- 3. Esophagus: anatomy andphysiology • 20-22 cm long, food conduit, muscular tube (skeletal and smooth muscle) • Unlike distal GIT, no serosal layer • Innervation: • Motor: Vagus nerve (NA skeletal muscle, DMNV smooth muscle) • ENS: Myenteric plexus (sparse in proximal esophagus) + meissner’s (sub- mucosal) plexus (sparse in human) • Sensation: Cervical esophagus by SLN + remainder by RLN
- 4. • Peristalsis: Normally atonic,intraluminal pressure ~ pleural pressure Primary: initiated by swallow and traverses entire length of esophagus Secondary: eliciated in response to focal esophageal distension with air, fluid, or a balloon, beginning at the locus of distension Deglutitive inhibition Excitatory NT: cholinergic Inhibitory: NO + VIP
- 5. • EGJ: 3 contributors:LES + crural diaphragm + gastric cardia musculature Resting LES tone: 10-30 mm Hg relative to intragastric pressure HRM: EGJ contractile integral 28 to 125 mm hg/cm LES contraction: myogenic + neurogenic LES relaxation: Triggered by distension from either side of EGJ or swallowing Deglutitive LES relaxation: Vagus nerve, NT NO + VIP The LES relaxes during initial phase of swallow, but it does not actualy open until bolus enters LES, thereby implicating intrabolus pressure
- 6. • Transient LESrelaxations (tLESRs): To selectively permit gas venting of the stomach Occur most frequently in postprandial state during gastric distension Distinguished from swallow-induced relaxation: 1. Prolonged (>10 S) and independent of swallowing 2. a/w contraction of distal esophageal longitudional muscle esophageal shortening 3. No synchronized esophageal peristalsis 4. a/w crural diaphragm inhibition
- 7. High Resolution Manometry(HRM) • Gold standard for evaluating esophageal motility. • First conceptualized by Ray Clouse in 1990 as a replacement for conventional esophageal manometry • Clinical introduction: Early 2000s • Diagnostic tool: 2008 • Indication: • Evaluation of peristalsis and EGJOO • Evaluation of functional dysphagia, Non-cardiac chest pain • To assess esophageal peristalsis before anti-reflux surgery
- 8. HRM Cont.. • Pressuresensor technology • Software system: real-time plotting of spatiotemporal pressure topography Esophageal Pressure Topography (EPT) aka “Clouse Plots” • HRM Systems: 22-, 24-, or 36-channel Water Perfusion System (WPS) Less expensive Drawbacks: tedious maintenance, limited energy frequency response, challenging to set up and use, susceptible to artifacts Solid State Manometry (SSM) Most frequently used High frequency response Easier to use Drawbacks: more expensive, fragile, lower tolerance among pts
- 9. • CCv4.0 recommendsusing any SSM with < 2 cm of sensor spacing • Typical SSM catheter from Medtronic • 4.2 mm diameter and 36-channel pressure sensors at 1 cm intervals. • Each sensor measures pressure over a length of 2.5 mm by an array of 12 circumferential solids state micro-transducers single value at each channel level • Simultaneous measurement of pressure throughout the entire esophagus, spanning from UES to proximal stomach. • High Resolution Impedance Manometry (HRIM) • HRM sensors + 18 impedance sensors spaced 2 cm apart • Allows visualization of the movement of bolus within esophagus
- 10. Evolution of ChicagoClassification 2009 2011 2015 2019
- 11. Key priorities andupdates in CCv4.0
- 12. HRM CCv4.0 Recommendations Standarizationof HRM study protocols Diagnostic thresholds HRM metrics definitions Provocative maneuvers Update on classification of ECG, Peristaltsis disorders
- 13. Recommendations for Preparationand positioning of the patient for HRM as per CCv4.0 • Fasting > 4hrs for achalasia or delayed gastric emptying • Avoid medications which may impact peristalsis (e.g. CCBs, Nitrates) • H/O Previous foregut surgery (e.g. fundoplication, myotomy, hernia repair) THERMAL COMPENSATION C/I Altered mentation Structural obstruction Abnormal nasal passages Abnormal esophageal anatomy Frank aspiration Coagulopathy
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- 16. Assessment of HRMmetrics
- 17. HRM Metrics andThresholds Moderate GRADE, SR Low GRADE, SR
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- 19. Effect of positionon esophageal motility in healthy subject Compared to swallows in the supine postion, esophageal contractions in the upright position have increased velocity (↓ed DL) and ↓ed vigor (↓DCI) # Gravity ↓mechanical work
- 20. Provocative Manometric measures Indications: Demonstrate peristalticreserve Induce abnormal motility (in case of unequivocal result) confirm diagnosis
- 23. HRM recording ofa solid test meal
- 26. CCv3.0 HRM Proctocolfor classification of Esophageal Motility Disorders
- 28. Manometric Definitions CCv3.0Vs CCv4.0
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- 32. EGJOO sub-types Clinically relevant ECGOO Manometric ECGOO+ 1. Clinical symptoms (e.g. dysphagia, non- cardiac chest pain) 2. Supportive tests: TBE, FLIP
- 33. Disorders of Peristalsiswith Reduced Contractile Vigor or Continuity of Peristalsis
- 34. Disorders of Peristalsiswith Esophageal Spasticity or Hypercontractility
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