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Pathophysiology of
Esophageal Motility
Disorders
Thomas W. Rice MD
Traditional manometry
20 cm
15 cm
10 cm
5 cm
LES
MANOMETRY CATHETER EVOLUTION 1960-2010
Conventional
manometry
High Resolution Manometry
Free selection mode Topographic display
mmHg
HRM - Advances
Intraluminal pressure measurement
sensors every 1 cm
computer interpolation between sensors
Display
pressure topogram
y-axis
position
x-axis
time
color
pressure
High Resolution Manometry: Events and effect on pressure
Esophageal Body
Hypotensive Peristalsis: Assess Bolus Transit ?
Mild
Severe
Normal
Terminology - Peristalsis
Normal
< 3cm defect in 20 mmHg isobar
CFV < 9 cm s-1
IBP < 15 mmHg
DCI < 8000 mmHg cm s-1
Bredenoord AJ, et al. Neurogast & Mot 2012;24:57
Lower Esophageal Sphincter
(LES)
LES Function
Integrated Relaxation Pressure (IRP)
(Normal <15 mmHg)
5 sec
Four noncontinguous intervals totaling 4 sec in 10 sec window after UES relaxation.
Rice T, Shay S. Sem Thor and Cardiovas Surg 2011; 181-90.
LES Morphology
Subtypes of LES-crural diaphragm (CD) pressure
morphology
Pandolfino, Fox, Bredenoord, Kahrilas. Neurogastroenterol Motil 2009;21:796-806.
Hierarchical Analysis of Esophageal Motility
based on the Chicago Classification
Esophageal
motility
disorders
IRP = LES relaxation; normal <15 mmHg; Normal distal latency >4.5 sec; Breaks
large >5-cm, small 3-5 cm; Nutcracker is DCI 5-8,000; Rapid contraction <9 cm/sec
1.
Primary motility disorders should be considered as cause of dysphagia and/or chest pain only after first evaluating
for structural disorders, EoE, and cardiac disease.
2.
Branch 4 abnormalities can be seen in a normal population and clinical significance remains to be established.
Bredenoord A, Fox M, Kahrilas P, Pandolfino J, Schwizer W, Smout A, et al. Chicago Classification criteria of esophageal motility disorders
defined in HRM esophageal pressure topography. Neurogastroenterol Motil 2012;24:57-65 (supp).
Achalasia
Hierarchical Analysis of Esophageal Motility
Note: IRP = LES relaxation; normal <15 mmHg
1.
Primary motility disorders should be considered as cause of dysphagia and/or chest pain only after first evaluating
for structural disorders, EoE, and cardiac disease.
2.
Branch 4 abnormalities can be seen in a normal population and clinical significance remains to be established.
Bredenoord A, Fox M, Kahrilas P, Pandolfino J, Schwizer W, Smout A, et al. Chicago Classification criteria of esophageal motility disorders
defined in HRM esophageal pressure topography. Neurogastroenterol Motil 2012;24:57-65 (supp).
Achalasia
- Simultaneous contraction,
- LES high, poor relaxation
Normal
THREE TYPE OF ACHALASIA
Type I 1
Type
75
50
25
Pressure
Scale
Pharynx
Pharynx
Pressure
Scale
Type
Type 3
3
Type 22
Type
50
25
Pressure
Scale
75
50
25
100
UES
UES
75
100
75
50
25
25
100
13-cm
50
75
25
50
25
25
50
25
75
50
100
Gastric
25
75
25
75
50
25
100
LES
50
50
100
3-cm
3-cm
25
50
75
LES
50
100
75
Gastric
75
75
8-cm
8-cm
13-cm
75
Note: Type 2 has the best results with treatment
75
50
25
CCF © 2009
EGJ Outflow
Obstruction
Hierarchical Analysis of Esophageal Motility
Note: IRP = LES relaxation; normal <15 mmHg
1.
Primary motility disorders should be considered as cause of dysphagia and/or chest pain only after first evaluating
for structural disorders, EoE, and cardiac disease.
2.
Branch 4 abnormalities can be seen in a normal population and clinical significance remains to be established.
Bredenoord A, Fox M, Kahrilas P, Pandolfino J, Schwizer W, Smout A, et al. Chicago Classification criteria of esophageal motility disorders
defined in HRM esophageal pressure topography. Neurogastroenterol Motil 2012;24:57-65 (supp).
Functional obstruction EG Junction
5 mmHg
A
B
5 mmHg
A – Very high Intrabolus pressure: mean 55 mmHg
B – Increased contraction pressure: 250 mmHg
Normal EG Junction
70 mmHg
3 cm/s
Normal <25 mmHg
Normal <180 mmHg
Occurs in: Tight wrap; stricture; paraesophageal hernia; EoE; etc
Spastic Disorders
Hierarchical Analysis of Esophageal Motility
Note: DCI = Measure of esophageal contraction strength; normal <5,000
1.
Primary motility disorders should be considered as cause of dysphagia and/or chest pain only after first evaluating
for structural disorders, EoE, and cardiac disease.
2.
Branch 4 abnormalities can be seen in a normal population and clinical significance remains to be established.
Bredenoord A, Fox M, Kahrilas P, Pandolfino J, Schwizer W, Smout A, et al. Chicago Classification criteria of esophageal motility disorders
defined in HRM esophageal pressure topography. Neurogastroenterol Motil 2012;24:57-65 (supp).
DIFFUSE ESOPHAGEAL SPASM
DL
Normal peristalsis > 30 mmHg
Distal latency – 3.1 s (nl<4.5)
Simultaneous >30 mmHg
Jackhammer Esophagus
(Hypercontractile esophagus)
DCI >8,000 with repetitive contractions
Roman S, Tutuian R. Esophageal hypertensive peristaltic disorders Neurogastroenterol Motil 2012;24:20-26.
Peristaltic Abnormalities
Hierarchical Analysis of Esophageal Motility
based on the Chicago Classification
Esophageal
motility
disorders
IRP = LES relaxation; normal <15 mmHg; Normal distal latency >4.5 sec; Breaks
large >5-cm, small 3-5 cm; Nutcracker is DCI 5-8,000; Rapid contraction <9 cm/sec
1.
Primary motility disorders should be considered as cause of dysphagia and/or chest pain only after first evaluating
for structural disorders, EoE, and cardiac disease.
2.
Branch 4 abnormalities can be seen in a normal population and clinical significance remains to be established.
Bredenoord A, Fox M, Kahrilas P, Pandolfino J, Schwizer W, Smout A, et al. Chicago Classification criteria of esophageal motility disorders
defined in HRM esophageal pressure topography. Neurogastroenterol Motil 2012;24:57-65 (supp).
Terminology - Peristalsis
Weak
Large breaks in 20 mmHg isobar (> 5cm)
Small breaks in 20 mmHG isobar (2 – 5cm)
Frequent Failed
>30% but <100% of swallows with failed peristalsis
Rapid Contraction
20% of swallow with rapid contraction, DL < 4.5 s
Hypertensive peristalsis
Mean DCI > 5,000 mmHg-s-cm, but not meeting spastic
criteria (Nutcracker esophagus)
Bredenoord AJ, et al. Neurogast & Mot 2012;24:57
Hypotensive Peristalsis: Assess Bolus Transit ?
Mild
Severe
Normal
DISTAL LATENCY (DL; Nl >4.5 SEC)
CONTRACTILE FRONT VELOCITY (CFV; Nl <9 cm/s)
CDP: Contractile deceleration point
Pandolfino J, Sifrim D. Evaluation of esophageal contractile propagation using esophageal pressure topography.
Neurogastroenterol Motil 2012;24 (suppl 1):20-26.
Three Abnormal Contraction Types
Based
on Distal Latency (DL; Nl>4.5) and Contraction Front Velocity (CFV;Nl<9 cm/s)
Premature + Rapid
Premature only
Rapid Only
Pandolfino J, Sifrim D. Evaluation of esophageal contractile propagation using esophageal pressure topography.
Neurogastroenterol Motil 2012;24 (suppl 1):20-26.
Nutcracker Esophagus
300
Pressure
Scale
200
100
B
Pharynx
Pressure
Scale
Pharynx
(Hypertensive peristalsis
(Mean DCI>5,000))
A
200
100
UES
UES
300
200
100
13-cm
13-cm
300
200
100
8-cm
8-cm
300
200
100
3-cm
3-cm
300
200
100
LES
LES
300
200
100
Gastric
Gastric
300
CC
Antegrade esophageal contraction (CFV <9)
Increased contraction amplitude (DCI - 6,100)
Roman S, Tutuian R. Esophageal hypertensive peristaltic disorders Neurogastroenterol Motil 2012;24:20-26.
Scleroderma Esophagus: Hypotensive LES (<5 mmHg); no
smooth (but normal striated) muscle contraction
LES