Gastroenterology and Hepatology - Upper GI Motility Disorders

8/22/2019 Gastroenterology and Hepatology - Upper GI Motility Disorders

1/36

Upper GI Motility Disorders

Ron Schey, MD

Clinical Assistant Professor

Division of Gastroenterology & HepatologyUniversity of Iowa Hospitals and Clinics


2/36

Dysphagia


3/36

50 y.o male

3 months of dysphagia solids and liquids

Weight loss 10 lb

PMH: Asthma INH-Beta 2 agonists/steroids

Hypertension ACE Inhibitors

NIDDM- Diet controlled

GERD H2 Blockers (sos)PSH: None


4/36

Main esophageal symptomsHeartburn- Characteristic Symptom of GERD

Regurgitation- Another characteristic GERDsymptom

Dysphagia - Difficulty in swallowing

Odynophagia - Pain on swallowing

Nonspecific esophageal symptomsGlobus Hiccups

Chest Pain Nausea/vomiting

Rumination Belching


5/36

Esophageal Anatomy

UES

LES

Striated

Muscle

Smooth

Muscle

20 -22 cm long muscular tube

Inner circular layerOuter longitudinal layer

Sphincters at each end

Myenteric plexus between layers

Flat network of nerve cells

and axons

TransitionZone

Upper 5% striated muscle

Middle 35-40% mixed Lower 50-65% smooth muscle


6/36

UES

LE

S

Esophageal Function

Tubular Esophagus

Peristaltic ring contractions

Longitudinal shortening

Lower Esophageal Sphincter

Tone at rest (myogenic)

Relaxes with swallows

Upper Esophageal Sphincter

Maintains tone at rest (neurogenic)Opens with swallows


7/36

Control of Esophageal

Motor Function

Striated Muscle - CNS Control Nucleus ambiguous

Motor end-plates

UES tone- tonic neural activity

Peristalsis-sequential motor

neuron activation

Smooth muscle control - ENSDorsal motor nucleus -

myenteric neurons -

muscle

Timing of peristalsis -NO

Strength of peristalsisAch/SP

LES tone myogenic + Ach/NO

Relaxation NO


8/36

Mechanical obstruction

Neoplasms (Intrinsic and Extrinsic)

Peptic stricturesForeign body

Paraesophageal hernia

Esophagitis (Peptic/Infectious)

Neuropathy - Achalasia, HIV

Myopathy


9/36

Neuromuscular diseases

CNS( stroke, MS, ALS, Parkinsons, Tumor)

PNS (Polio, MG, Neuropathy, DM)

Myopathy (MD, Polio)

Structural AbnormalitiesNeoplasm (Squamous Cell CA, Lymphoma)

Infection (Candida, CMV)

Cricopharyngeal Bar/Zenkers Diverticulum


10/36

Myopathic DiseasesSmooth Muscle Esophagus

Collagen Vascular Diseases (CREST,

Scleroderma, SLE)

Muscular Dystrophies Familial Visceral Myopathies

PathologyMuscle degeneration and replacement by fibrous connective tissue


11/36

Heartburn-RefluxEsophagitis Esophageal strictureMotor abnormality

Odynophagia - Severe Inflammation (ulcer)Infection (CMV, Herpes, Candida)Peptic esophageal ulcer

Pill esophagitis


12/36

Identification of esophagitis

Identify infections in immunocompromised patients

Exclude pseudo-achalasia before treatment

Treatment of esophageal diseases (peptic stricture, tumor,achalasia)

Identifyeosinophilic esophagitis


13/36

Peptic Esophagitis


14/36

Peptic Stricture


15/36

Schatzki Ring


16/36

Candida Esophagitis


17/36

Paraesophageal Hernia


18/36

Nissen Fundoplication


19/36

Eosinophilic Esophagitis-Histopathlogy

Number of Epithelial Eosinophils/HPF, n (Range)

Proximal Esophagus 78.7 (2-158) 25.6 (0.2-69.6)Distal Esophagus 117.5 (29-402) 37.6 (3.8-109)

Eosinophils Superficial and form Microabcesses

Insignificant Number in Antrum and Duodenum

Basal Cell Hyperplasia, % (Range) 65.1 (20-80)

Papillary Hyperplasia, % (Range) 79.7 (50-90)

Remedios, et al. Gastro. Endoscop. 63: 3-12, 2006Straumann, et al. Gastro. 125:1660, 2003.


20/36

FoodImpaction


21/36

Adenocarcinoma of the Esophagus


22/36

Barium esophagram/Videoesophagography

Upper endoscopy

Esophageal manometry

Water perfused catheter

Solid state catheter Dent sleeve

Impedance Manometry

High Resolution, Multichannel

Esophageal pH monitoring Catheter (+/- impedance)

Wireless Bravo (endoscopic placement)

Esophageal transit and GE reflux scintigraphy


23/36

Obstructive Lesion vs Motor Abnormality

Upper Esophageal Webs or Strictures

Cricopharyngeal BarZenkers (Pharyngoesophageal) Diverticulum

Schatzkis Ring

Intramural LesionsCompression by Extraesophageal Lesions

Compliment to Manometry - Bolus Transport


24/36

Diffuse Esophageal

Spasm


25/36

Diffuse Esophageal Spasm

Striated muscle - normal

Wet swallows - produce simultaneous

pressure waves in smooth muscle esophagus with

Periods of normal peristalsis

Occasional spontaneous pressure waves

Repetitive contractions (>2 peaks)Prolonged duration pressure waves (>6 sec)

High amplitude pressure waves

A h l i


26/36

Achalasia

Barium Swallow

Birds beak at LES

Failed LES relaxation

Dilated esophagus

Sigmoid esophagus

Failed 1o peristalsis

A h l i d


27/36

Achalasia - Endoscopy

Rule out pseudo-achalasia


28/36

1A conventional


29/36

22

25

28

32

36

40

44

513 sec

Distan

cefromNares

(cm)

Pharynx

UES

LES

Gastric

19

100

100

Pressure(m

mHg)

100

100

100

100

100

50

100

WS

manometry tracing

M t / Vid fl


30/36

Manometry / Videofluoroscopy

UES

cm

aboveLES

o

o

o

o

o

o

o

3.0 s

3.9 s

6.5 s

8.0 s

9.3 s

11.8 s

13.1 s

3.9

6.5

8.0

9.3

11.8

LES Open

3.0

0 10 20

11

9

7

5

3

1

LES0

160

Seconds

J. Ren, Am. J. Physiol. 261: G417, 1991

1B Transformation to 3D space


31/36

180

160

140

120100

80

60

40

20

Pressure

(mmHg)

p

1E. Transformation to color contour


32/36

180

160

140

120

100

80

60

40

20

1F. Transformation to 2D representation of color contour


33/36

3 sec

UES

LES

19

24

29

39

34

44

49

54

Cm

fromNares

0

20

40

60

80

100

120

140

mmHg

*

**

Striated Muscle

Transition Zone

Smooth

Muscle

p


34/36

SolidsMechanical Obstruction

Sudden

Foreign

Body

Intermittent

Schatzkis

Ring

Progressive

Heartburn

GERD

Stricture

>50 yo

Carcinoma

Eosinophilic

Esophagitis


35/36

Solids or LiquidsInfection/Neuromuscular

Recent

Immunosuppression

Antibiotics

HIV Infection

Candida

CMV

Intermittent

Chest Pain?

Motility

Disorder

Progressive

Achalasia Scleroderma


36/36

Common clinical problem

Between 70-80% patients Significant overlapbetween oropharyngeal and esophageal disorders-History & Tests often useful

Motility disorders are quite common- HRM,Impedance may provide novel information

Eosionophillic esophagitis should be recognized

Detailed evaluation reveals abnormalities in >60% of

patientsNon-obstructive, functional dysphagia remains a

challenge

Between 70-80% of patients can be helped with lifestyle modifications, drugs, endoscopy & surgery

Gastroenterology and Hepatology - Upper GI Motility Disorders

Documents

Transcript of Gastroenterology and Hepatology - Upper GI Motility Disorders