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DISORDERS
Approach to Diagnosis & Management
Dr Selvakumar B
Esophageal phase
UES relaxation
Propogative peristalsis – Primary (vs Secondary/Tertiary)
LES relaxation – dLESR (vs tLESR)
*Shackelford’s 7th Edition
Involuntary phase of swallowing
EXAMINATION:
e/o neurologic deficits – facial palsy, dysarthria, ptosis etc
alsoInspection
* May ofesophageal
be present in mouth/pharynx for structural lesions
dysphagia
**Harrison’s 19th Ed & Slazinger 10th Ed
Esophageal dysphagia
HISTORY**:
Localised to chest
Stickiness of food after initiation of swallow
H/o associated chest pain
H/o odynophagia – s/o ulcerated mucosa
Voice change/coughing while swallowing?
EXAMINATION:
Usually unremarkable
Skin changes may be seen in scleroderma and other connective
tissue disorders
Ba Swallow
Cheaper, easy to do.**
Superior for motility disorders, esophageal strictures, rings/webs
Helps plan UGIE – site of stricture, length of stricture
Best inv for tracheoesophageal fistula, oropharyngeal dysphagia
*Baker ME et al GERD: Ba esophagogram and antireflux Sx. Radiology 2007; 243(2); 329-39
Ba swallow
Conventional Manometry(CM)
*Ghoshal UC et al Eso function tests in clinical practice. Trop Gastroenterol 2010; 31(3): 145-54
CM
*Ghoshal UC et al Eso function tests in clinical practice. Trop Gastroenterol 2010; 31(3): 145-54
Sabiston’s 19th Ed Chapter 43, pg 1021
EPT - HRM
High Resolution Manometry(HRM) catheter
30-32 Radial solid state sensors placed at </= 1cm distance
Static pressure measurement
Simultaneous recording in Eso body, UES and LES
EPT – Real time 3D(time, distance in eso body and pressure) graph during a
swallow “The Clouse plot”
Spasm
EPT vs CM
The ‘Chicago’ Hierarchy
DL < 4.5s
Problems:
Chest pain
Dysphagia
Management:
Medical(Diltiazem, Sildenafil)/Endoscopic(Botulinum)
No Dysphagia
Problems:
Recurrent aspiration pneumonia
Peptic esophageal stricture
They are
Ineffective Motility (50% swallows with DCI < 450)
Fragmented peristalsis(50% swallows with breaks > 5 cms)
Pneumatic dilatation(PD)
Increased
Allaix MEage
et al.and Eso diameter
Treatment modalities for–Achalasia.
no poorer Surgoutcome
Clin N Am 95(2015) 567-78.
Incision:12-
13 cms
above GEJ
(3 cms)
3 cm distal to
mucosal incision
to 3 cm distal to
GEJ
POEM – a NOTES procedure
POEM outcomes
Von Renteln D et al Gastroenterol 2013;145:309-11. & Gut 2015 Apr 30 Online 1st
N = 80; Median myotomy: 13 cm
Significant mean LES pressure fall: 28 to 9 mm
Esophagitis on UGIE: 42%
Symptomatic GER: 37% at 1 yr, managed with PPI
Remission: 3m 97%, 6m 89%, 12m 82%, 24m 78%
Total Failure Rate at 24m: 22%
“POEM = LHC without fundoplication via a mucosal incision without GA”
Subjective assessment:
Symptoms: Dysphagia, chest pain etc
Symptom scores: Eckardt score </=3 – Weight loss, dysphagia,
retrosternal pain and regurgitation
QOL scores
Objective assessment:
TBS: Eso emptying at 5 min; Most relevant clinically
Manometry: LES pressure < 10mm - long term success
LES distensibility: EndoFLIP
Treatment failures
Graded PD failure: 23-33% over 5-7 yrs
LHC/Repeat PD
Higher complications*
N = 201**; Endosc failure 154(100 PD, 33 EBTI, 21 both)
Intra-op complications: 9.7% vs 3.6%**
Eso perf occurred only in prior endoscopic failure group
Post op complications: 10.4% vs 5.4%**
Outcomes: Controversial
Equivalent outcomes* vs Higher failure(19.5% vs 10.1%)**
*Portale G et al LHC outcomes: Detrimental role of prior endotherapy. J Gastrointest Surg 2005; 9: 1332
*Rosemurgy A et al. LHC salvage after Failed endotherapy. Ann Surg 2005; 241: 725
**Smith CD et al. Endotherapy before LHC leads to worse outcomes. Ann Surg 2006; 243: 579-86
ACG Clinical Guidelines
Static High freq USG*: EUS, circular muscle thickness and total muscle
area
*Mittal RK. Eso function testing. Gastrointest Endosc Clin N Am 2014; 24(4):667-85
**Familiari et al. EndoFLIP system. United European Gastroenterol J 2014;2(2):77-83
Summary