1. New Developments in Gastroenterology at West Herts High Resolution oesophageal manometry and 24 hour pH studies Dr Mark Fullard Consultant Gastroenterologist

2. Background Trained in South East Thames Region Trained in South East Thames Region Research at St George’s Hospital, London Research at St George’s Hospital, London MD 2008 MD 2008 –‘Studies in Gastro-oesophageal reflux disease with special emphasis on disease progression’ Appointed as consultant at West Herts April 2008 Appointed as consultant at West Herts April 2008 Special interest in oesophageal disease and oesophageal physiology. Special interest in oesophageal disease and oesophageal physiology.

3. Lower Esophageal Sphincter Upper Esophageal Sphincter Stomach Esophageal Body Epiglottis Pharynx

4. What is oesophageal manometry? Measures Measures –Upper oesophageal sphincter pressure and relaxation –Lower oesophageal sphincter pressure and relaxation –Motor function of oesophageal body Pass catheter through nose into oesophagus and stomach Pass catheter through nose into oesophagus and stomach Pressure sensors along catheter measure function of oesophagus in response to swallows of water Pressure sensors along catheter measure function of oesophagus in response to swallows of water

5. How is it done? Conventional manometry Conventional manometry –5-8 pressure sensors along catheter

7. How is it done? High Resolution Manometry High Resolution Manometry –36 circumferential pressure sensors placed along catheter

9. What is pH study? Digitrapper pH 100 1 channel Digitrapper pH 400 4 channels + LES perfusion port 1 or 4 channel 24 h pH recorder

10. LES UES Single channel pH Catheter Two channels pH Catheter pH sensor 5cm above proximal LES border pH sensor approx. 2-3 cm below UES For ENT positionning: Proximal pH sensor is placed approx. 1 cm above UES 15 cm between sensors

12. Indications for procedures Manometry Manometry –Dysphagia with normal OGD –Unexplained non cardiac chest pain –For patients considered for anti- reflux surgery –Prior to a pH study 24 Hr pH study 24 Hr pH study –Patients with symptoms of reflux not responding to PPI –Patients with normal OGD and symptoms that may be due to reflux –Patients being considered for anti- reflux surgery

13. ‘The old system ’ Referred to St Mark’s, UCL Referred to St Mark’s, UCL Travel to London Travel to London Waiting time recently up to 4 months Waiting time recently up to 4 months West Herts physicians and surgeons combined sent about 80 in last year West Herts physicians and surgeons combined sent about 80 in last year

14. ‘The New System’ Done by me Done by me HHGH HHGH Tuesday pm Tuesday pm Doing 3 patients per week Doing 3 patients per week Expect to do 80-100 per year Expect to do 80-100 per year Aim to do within 6 weeks Aim to do within 6 weeks Started 2 weeks ago Started 2 weeks ago Take referrals from Take referrals from –GI colleagues –Surgeons –Respiratory –ENT –GPs

15. Case study Second patient Second patient 28 year old man 28 year old man Two years intermittent dysphagia to solids and liquids Two years intermittent dysphagia to solids and liquids OGD normal OGD normal Barium swallow Barium swallow –‘No mucosal lesion, tertiary contractions, abnormal lower oesophagus, not achalasia’ Had high resolution manometry within 2 weeks of referral Had high resolution manometry within 2 weeks of referral

17. Patient Normal study No relaxation of LOS on swallowingLOS relaxes on swallowing Well propagated swallow Simultaneous, non-propagated weak swallow Diagnosis = Achalasia

18. Summary New Service New Service Useful applications Useful applications Local service been repatriated from London teaching hospitals Local service been repatriated from London teaching hospitals Less travelling for patients Less travelling for patients Quicker service Quicker service One of the increasing number of centres doing high resolution manometry as a routine One of the increasing number of centres doing high resolution manometry as a routine

19. Summary Happy to receive referrals Happy to receive referrals –Will see in clinic first Happy to discuss over phone or by e-mail Happy to discuss over phone or by e-mail mark.fullard@whht.nhs.uk Tel – 01442 287060