1. DYSPHAGIA - THE ROLE OF OESOPHAGEAL MOTILITY DISORDERS IAN WALLACE FCP(SA), FRACP. SHAKESPEARE SPECIALIST GROUP MILFORD, AUCKLAND

2. CAUSES OF DYSPHAGIA Stages of swallowing Oropharyngeal (Voluntary) Oesophageal (Involuntary)

3. CAUSES OF DYSPHAGIA HISTORY Oropharyngeal vs oesophageal body Duration and frequency (progressive?) Associated regurgitiation Associated reflux symptoms Solids to liquids vs solids and liquids EXAMINATION Lymphadenopathy Neurological

4. CAUSES OF DYSPHAGIA Structural abnormalities Oesophageal neoplasm Peptic stricture Shatzki ring Incarcerated hiatal hernia Oesophageal web Oesophageal diverticulae

5. CAUSES OF DYSPHAGIA Motility disorders Non specific motility disorder (ineffective oesophageal motility) Achalasia Eosinophilic oesophagitis Nutcracker oesophagus Diffuse oesophageal spasm Hypertensive LOS

6. CAUSES OF DYSPHAGIA MOTILITY DISORDERS Dig Dis Sci 1987;32:583

7. CAUSES OF DYSPHAGIA MOTILITY DISORDERS Special investigations Baseline bloods CXR Endoscopy and mucosal biopsy Barium swallow (marshmallow) Oesophageal manometry

8. Normal Swallow

9. 32 Pressure Channels High Resolution Impedance-Manometry 8 9 10 5 3 2 11 12 13 14 15 16 17 18 19 20 21 22 23 7 1 0 24 25 26 27 -2 -3 -4 -5 -6 6 28 29 4

10. Impedance Technology Fundamentals Alternating Current Generator Current Generator

11. Impedance Technology Fundamentals Reflux Bolus Conducts Electricity & Current Flows Between Impedance Rings Current Generator

12. Impedance Technology Fundamentals High Impedance No Reflux Low Impedance Reflux

13. A single impedance channel will detect bolus movement through the oesophagus Multiple impedance channels are required to detect the direction of bolus movement Impedance Technology Fundamentals

14. 123456123456 PressurePressure Impedance Contour Plot View of Swallow with Normal Manometry & Complete Bolus Transit Esophageal Body Pharynx UES Esophageal Body LES Gastric

15. 123456123456 PressurePressure Manometry Waveforms Bolus Transit Waveforms Impedance Contour Plot View of Swallow with Normal Manometry & Complete Bolus Transit

16. ImpedanceImpedance Time Impedance Contacts Impedance Technology Fundamentals Bolus EntryBolus Exit Bolus Present

17. OESOPHAGEAL MOTILITY DISORDERS INEFFECTIVE OESOPHAGEAL MOTILITY Common in patients with chronic reflux Predictive of refractory nocturnal GORD Characterized by a hypo contractile oesophagus. (amplitude 30% of contractions) Failure of distal propagation of peristaltic wave

18. Oesophageal Motility Disorders Achalasia-Aetiology Idiopathic- 98 % Primary Secondary Familial Associated with other congenital defects Associated with degenerative neurological disease

19. Oesophageal Motility Disorders Achalasia - Symptoms Dysphagia – usually slowly progressive Regurgitation Chest pain and dysphagia Reflux symptoms

20. Oesophageal Motility Disorders Achalasia-Manometric features Normal to raised LOS resting pressures LOS fails to relax to gastric baseline Raised residual pressures Raised oesophageal baseline pressures Absent or chaotic low amplitude simultaneous peristalsis

21. Normal Swallow

22. Achalasia Tracing

23. Oesophageal Motility disorders Achalasia-Treatment Pneumatic dilatatation Risks Patient selection Botox injection Patient selection Surgery Gastro-oesophageal reflux a significant complication

24. Eosinophilic Esophagitis Definition: Presence of eosinophils in the squamous epithelium or deeper Number of Eosinophils/hpf ranged from 30 – 320 (mean 101) Various studies have used 15-30/hpf Oesophagus - an immunologically active organ Eosinophilic infiltration also seen in : GORD Eosinophilic gastroenteritis Collagen vascular diseases Infections

25. Allergy Profile Allergy history 90% Atopic illness46% Food allergy25% Family history of asthma43%  Blood eosinophils36%  IgE56% Positive RAST42%

26. Endoscopic features associated with EE Nonerosive changes extending along the whole esophagus Whitish pinpoint exudate or papules Granularity Loss of vascular pattern Linear furrow and fold pattern Rings Corrugation Focal stricture (often proximal) Long-segment stricture (small caliber esophagus) Linear sheering of mucosa after dilation

29. Eosinophilic Oesophagitis Treatment Options Acid suppression (PPI therapy) where there are reflux symptoms PLUS: Swallowed inhalers – e.g. fluticasone Antihistamine therapy (Loratidine) Corticosteroids Elimination diets where specific allergies are defined Role of Ranitidine Clin Gastro. And Hepatol.2004;2:523 - 530

30. Eosinophilic Oesophagitis - Conclusion EE, a condition seen in children now increasing identified in adults Should be considered in the relevant patient population & those not responding to standard reflux treatment Awareness and recognition of gross changes by endoscopists Importance of tissue sampling for subtle abnormalities Establishing correct diagnosis may prevent unnecessary interventions, e.g. fundoplication

31. OESOPHAGEAL MOTILITY DISORDERS NUTCRACKER OESOPHAGUS Most common cause of NCCP in those patients with an oesophageal motility disorder. Average distal pressures > 180 mm Hg. Peristalsis is normal so Ba studies usually normal. 90% present with chest pain.

32. Normal Swallow

33. Nutcracker Oesophagus

34. DYSPHAGIA CONCLUSIONS The symptom of dysphagia does not always indicate a physical obstruction Oesophageal motility disorders account for the majority of cases of dysphagia A normal endoscopy or Ba study does not exclude a motility disorder - role of oesophageal manometry Importance of mucosal biopsies of macroscopically normal mucosa