GI MOTILITY When Slow Doesnt Always Win the

GI MOTILITY When Slow Doesn’t Always Win the Race Presenter: Shirley Maltman, RN, CGN(c)

Disclosure I will be mentioning the Covidien Mano. Scan Manometry system and the Crospon Endo. Flip System in my presentation as products used by the Calgary GI Motility Clinic. There has been no compensation from either company.

Objectives • Discuss the correlation between symptoms and Manometry studies • Discuss conditions associated with Motility Disorders • Research studies that are in progress in Calgary

First a Quick Review

What is Esophageal Manometry? Esophageal manometry is a study used to assess pressures and motor function of the esophagus. This aids in the evaluation of how well the muscles in the esophagus work to transport liquids or food from the mouth into the stomach. Source: Medtronic Eso Training Resources

Why Order the Test? • • • Atypical chest pain Reflux (GERD or NERD) Dysphagia Chronic cough Pre-op assessment (Hiatal hernia repair, Fundoplication, Lung transplant)

Who Orders p. H/Motility Studies? • • • Gastroenterology General/Thoracic Surgery Respirology Lung Transplant Team Rheumatology

Esophageal manometry Source: Calgary Gut Motility Clinic

Basic Anatomy Source: Google

Swallow and Bolus Movement

Normal Source: Calgary GI Gut Motility Clinic

And Now for the Abnormal!!

Achalasia Type III Source: Google Type II Type I

Symptoms of Achalasia • Dysphagia for both solids and liquids which starts as an occasional occurrence but can progress to every mouthful • Regurgitation of food and fluid, especially when supine, and is often mixed with saliva and mucous • Chest pain or discomfort • Unintentional weight loss

Complications of Achalasia • If untreated in the early stages, the food that collects in the esophagus can spill into the lungs causing bronchitis, pneumonia, or chronic lung disease. • The retained food can also cause esophageal chronic irritation leading to fungal infections. • Other complications are weight loss, malnutrition, and an increased risk of esophageal cancer

Achalasia (Type III) Source: Calgary Gut Motilty Clinic

Achalasia (Type II) Source: Covidien

Achalasia (Type I) Source: Calgary Gut Motility Clinic

Treatment of Achalasia Medical • Medication: Nitrates (Isorbide dinitrate), Calcium Channel Blockers (Nifedipine) • Botox Injection into the LES which is temporary and may be repeated. • Pneumatic Dilation Surgical • Heller Myotomy (which may be done with or without a Loose fundoplication) • POEM (Peroral Endoscopic Myotomy) • Esophagectomy

Jackhammer Esophagus Source: Calgary Gut Motility Clinic

Jackhammer Esophagus Source: Google

Jackhammer Esophagus What is it? • Hypercontractile Esophagus in which the esophageal contractions are of a very high amplitude involving a majority of the esophagus with a prolonged duration.

Jackhammer Esophagus Symptoms • A squeezing pain in the chest • Difficulty swallowing, especially extremely hot or cold fluids • A feeling that an object is caught in the throat Treatment • Sildenafil (smooth muscle relaxant) lowers LES pressure and spastic contractions of the distal esophagus • Botox • Balloon Dilation • PPI (often ineffective) • Tricyclic antidepressants

Distal Esophageal Spasm Source: Calgary Gut Motility Clinic

Distal Esophageal Spasm What is it? ? • A condition characterized by premature, uncoordinated contractions of the esophagus, which may cause difficulty swallowing (dysphagia) or regurgitation. In some cases, it may cause chest pain • Linked with Nitric Oxide deficiency resulting in a disordered neural inhibition. May progress to Achalasia • GERD frequently co-exists

DES (Distal Esophageal Spasm) Treatment: • Calcium channel blockers, nitrates (both short and long-acting), anticholinergics, visceral analgesics (tricyclic agent or SSRO’s), and esophageal dilation. • Botox injection into the distal esophagus • Heller Myotomy or POEM for the rare refractory patient.

EGJ Outflow Obstruction Source: Calgary Gut Motility Clinic

Hypotensive LES Source: Covidien

IEM Source: Calgary Gut Motility Clinic

Respiratory & Lung Transplant § Respirology will order Motility/p. H to ensure chronic cough is not caused by reflux (acid or non-acid) § Done prior to lung transplants to ensure there is no underlying pre-condition

Hiatal Hernia § 1/3 -1/2 of our studies done are for pre-op assessment § There needs to be assurance of adequate esophageal motility prior to a Nissen Fundoplication and Hiatal Hernia repair

Hiatal Hernia Types Source: Google

Hiatal Hernia EGD View Source: Google

Hiatal Hernia Source: Calgary Gut Motility Clinic

Lap Band Source: Calgary Gut Motility Clinic

Post-Vertical Sleeve Gastrectomy Source: Calgary Gut Motility Clinic

Connective Tissue Disease Source: Calgary Gut Motility Clinic

Scleroderma Study • In conjunction with Rheumatology and Stem Cell Transplant Clinic (at Tom Baker Cancer Center) • Pre-transplant manometry assessment, 6 & 18 -24 months post-transplant. • 5 patients have had pre-transplant assessment • 3 patients have had 6 month post-transplant assessments…. .

Scleroderma Study(patient 1) Pre Stem Cell Transplant Source: Calgary Gut Motility Clinic Post-Stem cell Transplant (6 mos)

Scleroderma Study (patient 2) Pre-stem cell transplant Source: Calgary Gut Motility Clinic Post-stem cell transplant (6 mos)

Endo. FLIP(Functional Luminal Imaging Technology) • Endo. FLIP is a technology that simultaneously measures the area across the inside of a gastrointestinal organ (for example, the esophagus) and the pressure inside that organ. The ratio of the two measurements is called distensibility (stiffness). • We can measure just the LES (in cases of Achalasia or EGJ Outflow Obstruction), or both LES and esophageal body (in Eo. E)

Endo. FLIP Equipment Source: Google

Endo. FLIP Study • The patient is NPO for 4 hours prior to the procedure • The procedure may be done during endoscopy or in the Motility Clinic unsedated (most of our patients are done this way) • Local anesthetic is sprayed into the oropharynx • The balloon catheter is inserted orally into the stomach and is inflated to 30 ml. The balloon is then withdrawn into the LES.

Endo. FLIP Study • Measurements are taken at the LES. • The balloon is then deflated and withdrawn into the body of the esophagus. • Inflation of the balloon is in increments and the patient is carefully monitored for discomfort. • The procedure takes approximately 5 -10 minutes and is generally well-tolerated.

Endo. FLIP LES Source: Google

Eosinophilic Esophagitis (Eo. E) • Is an allergic reaction in which the lining of the esophagus reacts to allergens such as food or pollen • Eosinophils are normally in the GI tract, but in Eo. E, they multiply and produce a protein causing inflammation, leading to scarring, narrowing and excessive fibrotic tissue in the esophagus. This in turn causes symptoms of dysphagia or even bolus impaction.

Eosinophilic Esophagitis (Eo. E) • Confirmed with biopsy during EGD • Treated with PPI (for PPI-responsive Eo. E), elimination diet, steroids (Fluticasone or Budesonide orally), or dilation

Eo. E Esophageal manometry Source: Calgary Gut Motility Clinic Endo. FLIP

Eo. E study • EGD with biopsies (for diagnosis) • A dysphagia questionnaire, and Endo. FLIP are done after diagnosis and before treatment is started. • EGD and Endo. FLIP are repeated 3 -6 months and 12 -18 months after treatment is started.

Thank you for your attention! Source: Armadale Castle, Skye Maltman trip