Esophageal multichannel intraluminal impedance testing (MII)

Def:
Catheter-based method to detect intraluminal bolus movement within the esophagus.

Types:
1- MII combined with esophageal manometry (MII-EM)
2- MII combined with pH testing (MII-pH)

MI detected bolus movement: Changes in intraluminal impedance during swallowing and reflux. A drop in
impedance identifies bolus entry in a segment followed by a recovery once the bolus exits the impedance-
measuring segment. Changes in impedance progressing from proximal to distally indicate antegrade bolus
movement as seen during swallowing while changes in impedance progressing distally to proximally
indicate retrograde bolus movement as seen during reflux.

MII combined with esophageal manometry (MII-EM):

 Value:
Provides information about esophageal:
1- MII: Bolus transit
2- Manometry: Pressures
  Indications:
1- Dysphagia
2- Noncardiac chest pain
3- Heartburn/regurgitation
4- Preoperative evaluation: before antireflux surgery or endoscopic antireflux
procedures
 Results:
1- Complete bolus transit:
- Bolus entry: at the most proximal site (20 cm above LES)
- Bolus exit: in all three distal impedance-measuring sites (ie, 15, 10, and 5 cm
above the LES)
2- Incomplete bolus transit:
- Bolus exit: not identified at any one of the three distal impedance-measuring
sites
 Interpretation:
1- Normal Esophageal transit
2- Abnormal Esophageal transit:
- ≥ 30% of liquid swallows have incomplete bolus transit
- ≥ 40% of viscous swallows have incomplete bolus transit
 Diagnosis: Esophageal motility abnormalities:
Abnormal pressure and transit
Achalasia
Scleroderma
Ineffective esophageal motility
Distal esophageal spasm
Abnormal pressure only
Nutcracker esophagus
Hypertensive LES
Hypotensive LES
Poorly relaxing LES

Combined MII and pH (MII-pH):

 Value:
Detect esophageal GER (GERD & NERD):
1- MII: detects reflux presence, distribution, composition, and reflux clearance time
2- pH testing: characterize pH and acid clearance time  differentiate between GERD
& NERD
  Indications:
1- Quantification and characterization of GER:
- Incomplete or no response to acid-suppressive therapy with PPI
- Normal endoscopic findings
2- Atypical GER symptoms e.g., chronic cough
 Types:
1- Off PPI therapy:
- If GERD is not established as the cause of symptoms
- To optimize the chance of detecting reflux events
2- On PPI therapy:
- In resistant GERD when NERD is suspected
- High-dose acid-suppressive therapy (ie, a PPI at least twice daily before meals)
for at least one week before MII-pH testing
 Interpretation: based on:
1- Normative data from healthy volunteers
2- Association of symptoms with GER episodes (acid and non-acid)

(A) conventional pH catheter (diameter 2.1 mm) used to monitor gastroesophageal reflux and intragastric
pH, (B) multi-channel intraluminal impedance-pH catheter (diameter 2.1 mm) with impedance electrodes
(4 mm in length) set in pairs at 2-cm intervals. This allows for six impedance rings and one pH electrode in
the esophagus and a second pH electrode in the stomach. The pH sensor is placed 5 cm above the LES and
gastric pH at 10 cm below the LES.
Acid and non-acid reflux identified by combined MII-pH monitoring: Reflux is identified by changes in
impedance progressing distally to proximally as liquid advances from the stomach into the esophagus.
Information from the pH electrode is used to classify reflux as acid (ie, pH drops from above to below 4) or
non-acid (ie, pH remains above 4).

Off therapy On therapy (PPI twice daily)

(N = 60) (N = 20)
Esophageal pH data
Percent time pH <4 Total 6.7% 1.3%
Upright 9.7% 2.2%
Recumbent 2.1% 0.0%
Esophageal MII-data
Nr. reflux episodes Total 73 48
Acid 55 12
Non-acid 27 44
Normal values for combined impedance-pH monitoring based on 95th percentile data in healthy
volunteers off and on acid-suppressive therapy

Complications of MII:
1- Infection
2- Bleeding
3- Trauma to the nasopharynx or esophagus
Relative contraindications:
1- Prior nasal surgery or trauma
2- Coagulopathy or use of anticoagulants