Chapters Transcript Video Classifications of Esophageal Motor Disorders: Implications for Diagnosis & Treatment Presented by John E. Pandolfino MD, MSCI, Northwestern Memorial Hospital, Chicago, IL. uh, in lieu of potentially my voice cracking a little. I've had a couple lectures today, so bear with me my voice starts toe quiver a little bit. So I think that was a very appropriate way to start. Because once again, I think it's important to realize that you know, these classifications schemes that have been developed even for high resolution Manama tree can be applied, um, to conventional Manama tree or other particular hardware and techniques. Um, looking at motility. So it is not just something that specific to one particular technology or one particular manufacturer. It can be extended across all of that and even into convince Manama trip. Now, in the grand scheme of what we dio, I think Manama tree is a very important tool on. This is kind of my standard algorithm of how I approach patients who present with this Feige and Food imp action. Most of the time, I typically start, in fact, almost all of the time I start with an upper endoscopy. That's really to rule out a mechanical obstruction or structural abnormality and to perform biopsies to rule out the center for like a stoppage itis. Now, if I do my initial endoscopy, and this is negative. And or there is something that suggested esophageal motility disorder, like a potentially type lower stocks of sphincter. Maybe some bullets retention, Um, some abnormal secretions in the esophageal by Salvador body should be pretty empty. And if I see that by my suspected ankle Asia and then, of course, I moved directly on. I'm assessing somewhere monitoring Now. Typically, my goal here is really to discern whether or not they have a true primary motor abnormality to kill Asia. Absent contracted cities spasm or jackhammer on def. They don't and they have something that's more borderline, then certainly I'll treat them for gas. Missiles were reflux cities and potentially target visual hypersensitivity a za a component of maybe then presenting with functional space because by that time they will fulfill criteria for functional spaces. So Manama tree, in and of itself is a very crucial tool in the evaluation of this phase and patients with swallowing the soul orders. Now getting back to the polling question, you can clearly see here that I put together a slide that has a compilation of conventional Manama tree here in the red Tracings high resolution Manama tree in the white tracings and then a salvageable pressure topography in the color plot here on the right. And the crucial thing to realize here is that the color plots that you see on the right is really not high resolution. Ominous. It's actually the data analysis format that we used for high resolution, optical high resolution geometry is essentially just a increased number of centers spaced closer together. So, in fact, instead of having maybe the 3 to 5 centers that we would typically have conventional Manama tree as illustrated by the red tracings. Now we have anywhere from 22 to 36 recording sensors and line tracings toe analyze. But really, the transformation of or the transformative um, aspect of this particular technique and approach was really the development of the esophageal pressure. Topography by rate Klaus and what Ray did was he converted the pressure tracing data and numbers into a color format topography on based on a hot cold scale. So here hot Red is high pressure blew his low pressure, and by using a fancy averaging technique called interpellation, he was able to provide a seamless, dynamic representation of the entire swallow profile going from the aural pharynx through the upper south of center, extending to the strident muscle portion, this first segment of the esophagus to the smooth muscle segment of the esophagus, the 2nd and 3rd portion and then, of course, to the ISAF gastric junction down here and then even extending into the stomach. It's funny because occasionally we'll actually see gas or contractions of the migrating motor complex in this particular area. So this gives us a lot of very, very important amazing landmarks. And it's also allowed us to make measurements in a lot more accurate formats and and provided with a lot more detail because we we reduce movement artist. And many of these measurements that we did make in the past were really contingent on the fact that we can identify the start of the swallow and the location of the lower central stranger. So what we have now is capability of looking at this not so much as a analysis paradigm, but more akin to images you can. Sometimes you can just open up the study, and just by looking at this study, you will be able to discern the diagnosis that make many fancy measurements. But that being said, because we have how the technology in the detail, we have converted many of the measurements off conventional Manama tree into these new measurements. We didn't throw the baby out with the bathwater, but what we really did was just make them more accurate and make them more descriptive of what we're actually seeing. So, for instance, the I R P, which is the integrated relaxation pressure, has replaced the lower sphincter relaxes because it needs to do much more than just assessed the lower social Thank you really needs to provide us with a comprehensive evaluation of what the level of obstruction is at the top of gastric junction, whether that's a poorly relaxing Elliot or a mechanical obstruction. In addition, we also characterized parasol tick function, Um, in terms of being intact based on integrity, this practical, integral and distal A and C. Those are very important parameters that help us define whether something is ineffective, spastic or even in a jackhammer format, and then the last thing, which is really very descriptive and subjective. There's something called pressurization patterns and once again these air patterns that when you look at it. You know what the answer is? And they do have Pathan demonic significant specifically in type two local Asia and then, of course, in the G d Alfa instructions. So this represents the Chicago classification three point. Oh, and what this does is, or what it has done, in contrast to 2.0 was really bring back a few other of our old favorites, like ineffective software motility and what it also did was provide us with a little bit more, um, outcome, um, information and that how we discern or how we divide these groups now are based on this red line that you see across the center of the slider a little bit towards the bottom. And what this does is it divides patients into four categories into those that are truly disorders of primary motor function and those that are orders parasols that may be seen in asymptomatic controls. And we'll go through this and we'll go through each component a lot more detail. So the first group of disorders that you need to talk about the top or top Chicago classification, which is relegated to what the patient has an m. O i. R. p Now the i r p is that, uh, just pretty, uh, and the I. R P is greater than the upgrade of normal for the particular system that you're using, regardless of which one it is. And they do have different thresholds for normality. And if the patient has an abnormal I. R P and 100% Bell Paracelsus or Spasm thes particular patients will fulfill criteria for Ankle Asia. Whether they have Type 12 or three will depend body pattern that we'll see more about this detail in the upcoming slides. Now, in contrast, if the patient has an abnormal R P but still has sufficient evidence of parastatals is such that the criteria for Type three accolades are not met, then those particular patients are deemed to have an e d J outflow obstruction, which may be actually incomplete, expressed or ankle Asian evolution versus a mechanical obstruction. Now I want to briefly review the integrated relaxation pressure because once again it is the cardinal. Metric used the first portion of the evaluation and analysis for this classification. Now, as the name means, integrated relaxation pressure really integrates ah, lot of the components that are um very important or integrated into the development of flow through the Asafa Powell gas injunction. Now for the intention purposes of this particular slide. What I've done is I've actually taken a single swallow. I've changed the range of the swallow in terms of pressure from negative 10 2 50. But I wanted to highlight the pressure dynamics through the esophagus gastric junction during this particular swallow. Now what I've also done was I've actually also done in this particular swallow a simultaneous video Flora Skopje image, and I've actually placed a small clip at the square mall Columbia Junction, so that you could appreciate the length of the lower sophomore center and also the trajectory of the lower esophageal sphincter. This black line here represents the squamous columnar junction clip and really represents the distal aspect of the lower stop the sinker as it moves through and up into the chest during a typical swallow. Now, in a normal swallow, the lower social sexual moving anywhere from 1 to 2 centimeters into the chest. And it's very interesting that during the transient lower social sphincter relaxation, we've seen instances where the lower social sinkers moved at least 8 to 10 centimeters up into the chest so the lower santos sphincter is, or the DJs air very dynamic area and really needs to be considered much more detail than just focusing on the lower cycle sent to relax ation impression. Now, when we did utilize the lower Sato sinking relaxation NATO pressure when we space and we, um, measure this by using a single center place through the topical gastric junction. And you appreciate this looking at the dotted line, you can really see that many of the time that we were measuring the day your pressure during these particular smiles, we may have been measuring the inter gas or pressure. Now, is that what is important? Because then we're not really getting a good representation of the resistance flow through the esophageal gastric junction. And we could falsely perceived that people have normal Eli's from relax ation when in fact they actually have abnormal relax, ation and potentially an e t j out for obstruction. So what we found was that if you looked at the pressure signal that was occurring during the swallow from the transit zone on the factors that were driving the pressure that you are measured through the topic. Gastric Junction were a combination of three particular components. The lower, softer sphincter relaxation pressure, the E G J opening dimensions which were really defined by the cruel contraction and the cruel anatomy, the Heidel Canal. And probably the most important, the intra Bullis pressure that is driving the Assad ical gastric junction open and what you're seeing here, These pressure bands are really the intervals pressure compressed by the parent salted wavefront and propagates down the esophagus, pushing the booth junctions during this period almost swallowed, relaxed but not opened until bullets flow here at this particular point and then you can clearly see at this particular point so hence the term integrated relaxation pressure. Now, why do we make sure the relaxing force and so it it provides the mean value of the lowest brisket of pressure through the topic. Pastor Duncan, on this really based on mathematical models and statistical models showed us that if we use this time duration, it was the best discrimination nature of a CA when we looked at a cool Asia versus a normal patient cohort. So once again, it provided very high sensitivity and specificity. But by no means perfect, but certainly one of the one of the metrics that we have currently my ankle, or at least a T T outflow obstruction. So now, before we go further into the subtypes, make a lazy I wanna pass this over to Jerry, who's gonna give you guys another question that maybe maybe a little bit more challenging than than which technology used? Uh, Dr Panel. Fine or a polling question is not functioning, but I would like to request from all the participants. As you have your own individual questions, please type them into your goto webinar screen, and we will respond to them during the question answered. Time period. Dr. Panel Fino. So the polling question really focus on what? What does the i. R P measure? And I hope I said enough times that it measures a compilation of all of the forces that are driving e g. Open the intervals pressure three El es relaxation pressure And then, of course, the restricted diameters through the Ohio Canal or the coral contraction. So once again, just to make sure that we stay on track with our polling questions, even though you haven't been able to answer them. So I love this cartoon because this cartoon really reflects the natural history of a coll Asia and how we tend to see this in practice. This this happens every week when I see patients, and I can tell where they are in terms of the natural history phases. And my hope is always that they present in the early phase. Because these are the people tend to do very well, as opposed to the later phases when the patient presents with overt dilation, severe bowls, retention, weight loss and those are the patients that may require in the subject So early on, when patients typically present, they typically present with chest pain to space, and they start to lose weight because they start to avoid eating and they start to avoid certain foods, specifically solid food. Thes particular patients definitely present with a man in metric pattern of type two, Type three or e g. Alfa obstruction. Now, as they progressing disease, the softest starts to dilate, and then they start to lose the ability to discern these contractions on high resolution geometry. And then what you see is paint a softer pressurization type two pattern or maybe even an early type one pattern you can still see temperate. Eventually, as the disease progresses, they will eventually progress with type one accolades. And that's why you really have to intervene in these particular states during the earlier chronic phase way before they get to this late phase. Because otherwise these particular patients do very poorly. Now. This slide represents, um, the progression and the conceptual model of how I envision the pathogenesis of a violation in the natural history. So going forward, I always say this when I show the slide. I really wish I would have waited to subtype Vehicle Asia Classifications scheme until I had a better understanding of where e g. The outflow obstruction fit into this. Because really, e g. The outflow obstruction should be type one because it really is the earliest form of vehicle Asia. I've had a few patients now progress right under my eyes from each of the outflow obstruction the type to eight Malaysia and what you're seeing here is preserved parastatals. It's imperative GJ relaxation and pretty minimal Bullis retention. And when you look at the ganglion, the inhibitory gangland, you really don't see a significant reduction in the inhibitory ganglion. ATTN least on studies where we looked at the lower software sink. Now conceptually as the disruption or as the reduction in inhibitory ganglion progress and the obstruction remains and the esophagus begins to dilate. Then you start to develop this Type two pattern where the patients tend to have no evidence of contraction. And the contractions may be buried in the fact that there is bullish retention and significant pressurization here. So there may be a contraction where you can exhibit this on the floor. Aske opic image But once again, it's not visualized on Manama tree thes patients tend to have ah much more profound reduction in inhibitory gangling than the outflow obstruction patient. Now, as this continues to progress and you lose Mawr and Mawr inhibitory gangland is evidence in this cartoon here, and the esophagus dilates more and more because of the obstruction, you get to this pattern where there is really no evidence of any contract il ity and no evidence of significant pressurization. The's where patients were presenting along the later stages of chronic able Asia, to the point where they're the classic type one, and hopefully they don't get to the point where they have a signaling esophagus or significant an atomic confirmation where they will require the subject for treatment. Now, what about type Reigle age? Well, this is a group of disorders or a specific group that actually have abnormal El Es relaxation and E g outflow obstruction and a spastic disorder in the body of the esophagus. And really, what happens here is is that this is really a disorder where there is a defect and inhibition. But there still is evidence of excited Torrey activity. And what we're finding is that about 50% of these patients, when we look back at their cases, many of these patients were actually on narcotics, and there may be in a narcotic effect of this particular disorder. So maybe it's related to specifically to the medicine. The problem is the unfortunate most people in front of narcotics. We can't stop the narcotics, and we wind up treating the majority of patients as if they have true Edel Asia. That's not related to a medical illness or medical issue related to the medicines that were taken. Now, what we also find in this particular group is that these particular patients do not have evidence of a reduction in their inhibitory gangland, but may actually have a more qualitative defect in terms of the neurotransmitters that relax Theis official body in the lower social sector. So this might be not so much a disruption in the inhibitory gangland number, but maybe a qualitative defect and much more research needs to be done in order to discern that. Okay, now these are examples of two e g outflow. Obstruction is the highlight. The fact that you d d outflow obstruction is a heterogeneous disorder on the left and panel A, you see an e g outflow ankle Asia phenotype. Here's a nice example of propagating person sauces. If the little gap he referenced the locus of this large diverticular, this epic, frantic diverticular. This was a patient who classically had ankle Asia, despite the fact that they had Purcell's treated with a hell of my I do well, I'm trying to be patient, has a mechanical obstruction leading to an elevated RP. They still have Kevin and absolved, but they have really compartment station really amount of this mechanical obstruction in this philosophical. This is which would have style later over a guide for quite well patterns. No new CEO. A true a. Okay, now, in terms of Type three Eagle Asia, it's important to distinguish between true type three ankle Asia and indeed the outflow obstruction. And I probably get a few cases Ah, month when people send me these particular and part of that and because of the pollution of the dying boosted on and class of King type. Because now that we've enhanced our understanding off the role of this delays the parameter. We really relegated Type three facets, having a distal agency animal less than 45 seconds. And I'll tell you that we'll talk a little bit more about this in detail. But the lacy interval is really the time period from the upper esophageal center. Relax, ation start to the period of time or the time point where the contract out deceleration point is localized or the personal to contract away front intersects a period of time or time point. Um, and location is above proximal aspect of the lower south to center, so you can see in this particular example the lane samples 3.9 seconds in this particular example of 3.2 seconds. Very premature contractions happening simultaneously. Arizona, where the transition zone should be. In contrast, this is a nice example of patient, with some promising to stay here in the distal esophagus. Some pressurization. This is an ankle age Phoenix I presenting the helpful extreme. They have normal lady see greater than 4.5 seconds. And here's another example in the bottom pattern of occasion with a mechanical obstruction at the B. D. J, who clearly has evidence of obstruction. Three I r P is abnormal, but the distillate see in this particular patient is much more within the normal range. And just, you know, you can clearly see a right. So this just highlights the fact that although the I R. P is very mad, it's not perfect, went back and looked at what patients that we defined and treated as if they have a pretty much the gold standard for the diagnosis of April Asia. What we found was that the value of 15 was not perfect and was really dependent on the body path, so patients had Dell peristyle, Asus or absent contract. Il ity thes particular patients could actually have a diagnosis of a culture fulfilled within I R P less than 15. So we use a cut off of 10 millimeters per mercury in terms of patients who present with absent contracted city. Now that didn't make its way into three point. Oh, but it made its way into a caveat when you're dealing with the absent contract group. In addition, if you look at this particular slide, also, you can clearly see that the patients have Panasonic pressurization. We don't even really care what their i. R P is that is Pathan demonic for Type two a. Coll Asia. So once again, if the I. R. P is six millimeters of mercury because they have a short paying a salvageable pressurization, that patient is still classified as having tied to regulation. This slide represents a flow chart or algorithmic approach of how I used high resolution geometry in my evaluation of patients, once they've had a a normal endoscopy or potentially findings that would suggest the motility sort of like this operability, ation resistance or some evidence to retain food or diverticular. Always. My next step is High resolution Manama Tree, and then, once I obtain that high resolution Manama tree I usually have a pretty good idea of where these patients sick in terms of their FINA types on whether or not they fulfill criteria for Eagle Asia, E D. J outflow, obstruction or potentially one of the other primary motor map formalities. This particular algorithm is presented a very nice, um, review that we were asked Thio send into clinical gastroenterology hepatology with my mentor, Peter Guerrillas, that was published about a year and a half two years ago. So once again, this could be found in C D eight under panel Fino and gorillas. Well, let's move on to patients who have a normal RP. So what happens when you do the Manama tree? The i. R. P is less than, um, the upper limit of normal, but then they have significant abnormalities in Paris policies. Well, these disorders and the three main disorders in this particular group are distill esophageal, spasm, jackhammer esophagus and absent contract Il ity And really these really depend mostly on the abnormalities that we see. India stops your body. So we're gonna go back to this latest because it's a very important metric on which is t here in the A is the latest. He described with consumer Manama, Tree by Bahar and Being Connie on what Bahar and being Connie did was they mapped the trajectory of the contract away front, using conventional Manama tree in patients who had classic spasm, meaning that they had a corks tour esophagus on Fluoroscope E and those normal controls that have normal propagation. The purple dots here. So the red line or the red dots represent spastic disorders and the purple represent normal parasols. And what they found was that patients had a premature contraction. That was mawr of the path of demonic feature of spasm. And when we went back and looked at our patients, we saw that there were typical FINA types off propagation. So when panel see here, you can clearly see that this is a rapid, premature contractions. This contraction lines up very nicely along the contour or the propagation of spasm defined by the harm being Connie. And you can clearly see the court's ruling of your Sophos in this particular patient on their respective for stopping image. Now, when you look at this middle panel, this is someone who actually has a distillation of all off 4.4 seconds. And you can clearly see that although this very normal, there's a Jordan just the links, you know. And I have to admit that this is someone who initially I called off possible borderline maybe e t j outflow obstruction and eventually, a year or two later, they actually presented with through the Malaysia, uh, solution and provide the reducing, um Lindsay Interval, as opposed to the parasol tick velocity which in this particular example was normal at 6. 72 seconds finally represents another nice variant of propagation. And in fact, in this particular patient, I would have called this phantasm five or 10 years ago because the contract out front velocity of Paris top velocity was 15 70 per second. What would you see here is that this is really driven by this fragmented Paris analysis. And what's more important here is that this is actually one of our recent dramatic controls. This is actually my nurse who has no past nurse who has no assumption symptoms, who was one of our asymptomatic controls. And if I would have seen this, I would have actually diagnosed her inappropriately is having spasm despite the fact that she has no symptoms whatsoever, and that was purely based on the contract out front velocity. But what you can clearly see here is that this particular swallow has normal late Sandoval. So in these days or nowadays, I would never call this fast it swallowing. Just basically call this ah, fragmented contraction based on this parasol to defect. So why is this important? Well, it's important because I went back and I actually show that I misdiagnosed patients at a very high level when I was diagnosing patients with spasm before the introduction of this the late. So this is an example of over 1000 consecutive patients who had clinical deputy studied, and when we went back and looked at this, I actually diagnosed 91 patients with based on their contract out front velocity. However, when I went back and looked at these particular patients that I misdiagnosed with spasm, what I found was was that the majority of these patients almost two thirds of them actually had normal distillates. And when I actually looked at their studies now, in hindsight, 39 of them had weak parasol asses. 14 of them have normal Paracelsus and the other you know, 14 of these particular people actually wound up having either repurposed assists with technical contractions, hypertensive Paracelsus or functionally gj outflow obstruction. Now, what I also found was that true spasm was very rare. In fact, Onley 24 patients actually had true spasm, and the majority of these particular patients actually had Type three a Galatians. So once again, it's really helped us refine our clinical FINA attempts of a Malaysia. Now this was the point where I supposed to give you another polling question when I asked you what the path a demonic feature of true spasm is. And the answer, obviously, was this lady. So we'll we'll forgo the polling question and go on to the next segment, which is really going to focus on the hyper contract. I'll esophageal disorders, the hypertensive disorders or the Nutcracker variance. Either way, how you how you want to use that particular terminology, the long and short of it is is that what we see here is the progression from a normal swallow to the middle panel, where there's a slightly hypertensive contraction, a nutcracker like contraction, and then this really aberrant abnormality called jackhammers office, where you see pretty normal propagation and contraction, uh, contract vigor. But these repetitive contractions over a very long, um, now these particular abnormalities, they're not really abnormalities that are basically focused on contract. How vigor or contract I'll amplitude but more on the period of isometric relaxation. Theus, aka should essentially be relaxing here, and it's not really that's the primary abnormality and Jack camera soft. It's well, how do we define cameras office when we define it, using something called the distant contracted integral in the beginning of the presentation of really talk a little bit about that? It does. If it takes all of the contract, I'll in information length of the SA vigil body and during the duration of the contract l event and essentially putting this into an integrated format, whether the measurement, um Hendricks are in a, uh, millimeters per mercury second per centimeter. So the industry that we typically use here, um, focuses on not just that the contract I'll amplitude or measurement of contract on pressure, but also the duration of the contraction and the length of the contraction. Now, the last primary motive disorder is something called absent contracted city, which is incense complete absence of Paracelsus with no evidence of contraction. There is a very nice example. This happens to be a scleroderma patients. However, we do not call the square enormous topics anymore because it's not path demotic of scleroderma. What we see here in these particular patients is the fact that they have complete lack of body pursed office. And some of these patients may have a complete lack of pressure of the intrinsic lower south to center here, which would predispose them to significant reflux. So in these particular patients, you do not see this pattern in asymptomatic control controls asymptomatic controls, never present with complete absence contract il ity. And if you see that that it's certainly abnormal. And when you see this, it certainly should be something that would make you suspect that this is really implicated in patients. Present representation of this Basia and gas yourself to reflux. So what do we do about the minor disorders of Paris? Tosses well, these air disorders, where Paracelsus is associated with very mild abnormalities. You can find this in asymptomatic controls and the primary defect is really related to impaired bowls transit. And once again we go back to ineffectiveness, opportune motility and fragmented Paris. False is well, just like hyper contract our Paracelsus. We also have a d c I threshold for a week or effect swallow. And they failed. Well, um, if the D c is less than 450 then we would consider this an ineffective swallowing. Here are two nights examples in paddle and paddle. See, you can clearly see in both of these examples, um, the D. C is less than 450 this particular example panel A. There's a very large defect, um, in the Paris topic. Different now this slide represents the Phoenix types of, in effect stop doing motility and you can clearly see it here. There's a progression from absent contract il ity to this other swallow which, although there happens to be some evidence of some propagation here, the d. C I value is less than 100 we would consider this a failed swallow despite the fact that there is some attempt here false iss on contraction. And then, of course, this would be a beautiful week. First off the event with some very mild defects and this represents fragmented Paracelsus this is that transition zone defect. The length here is greater than five centimeters, but the D. C. I hear and still greater than 450. So this has normal contract are bigger, but certainly a very large defect that certainly patients can present with philosophic Ghitis, approximately approximate regurgitate agent and a sensation that food is getting stuff in the proximity esophagus. Here's a very nice example with simultaneous, um, in peons showing poor bowls transit with these absent contract tile swallows. And then, of course, you see a little bit of a fragment here with some bullets retention. And then here another swallow with the significant, um, very weak defect here with some significant bullets, retention and bullets escape. So once again highlighting the fact that these air mild disorders that are associate with polls retention so once again in somewhere in this is the Chicago classifications 3.0. What you see here is the reintroduction of ineffective south remotely ineffective swallows greater than 50% on then, of course, fragment peristyle assist. They may have a normal D c I, but they have swallows where there is a defect sides greater than five centimeters And then, of course, if they don't fulfill any of these criteria, we consider these normal esophageal motor function. But once again, in the context of the patient was presenting with a symptom. So they're not the same as asymptomatic controls. But certainly there is nothing that we would do to target improving esophageal motility in these particular patients. So now I'm gonna shift gears for ah, a few more minutes and really focused on what we're going to consider for Chicago. Four point. Oh, so probably the lowest hanging fruit here, in terms of evolving the Chicago classifications and high resolution Manama Terry has to be the introduction of impedance that helping refine the classification scheme and how we utilize this particular technology is an outcome. Metrics, This is a very nice example where what you see here is not on Lius option to pressure topography, but what you're seeing here is impedance topography. So this purple color here represents liquid because the lower the impedance signal, the more dense of purple color there is. So what you see here in this particular swallow is a little bit of an air pocket here, the liquid. So this is a mixed air liquid swallow and you can see beautiful propagation of the contraction with almost complete transit of the bullets, with maybe a little bit of both retention here, that is insignificant. So this is an avenue to combine high resolution Manama tree with impedance to get the best of both worlds in terms of bullets, retention, bullets, transit and the contract. Our activity. Well, the first thing we saw was extremely helpful. We're gonna be most helpful was in a coll Asia because when we were doing these particular studies, what we found was was that if you looked at type two ankle Asia, there was always this this purple marker of Polish retention on what we found was when we compared the time barrier, cassava grams with, um, this particular format of using impedance topography. We clearly saw that there was a pretty good correlation with these particular, uh, indices. So if you looked at the column height on Farrah Skopje and and the impedance balls height on H rim, they looked like they correlated pretty well. You saw this also, if you took away the overlay presentation and you saw the bulls retention, it matched up almost perfectly when we looked at patients over and over. So we did perform a study where we asked to look at and compared in the same page in different H. R. I am there H rim study and their time Baron stop Graham. And what we found was that there was a pretty correlation on that. This competing goals hype could be used as a very important relevant outcome measure in patients who have undergone intervention in a Coll Asia. So now we've been pushing the envelope a little bit more by looking at we continue this impedance topography and leverages to look at, um impedance signals bullets transit in a much more detailed way and by looking at something called the ESOP Olympia integral ratio meaning that the level of impedance signal here on the level of the impedance signal here. So before during this swallow before Paracelsus and Paracelsus, we could get a better sense of how much of Ebola's was left behind after a swallow. And our hypothesis was was that even though impedance in of itself, when you look at incomplete and complete polls, transit wasn't all that helpful in discerning true symptoms in patients with this, Faiza, if we could quantify this with a little bit more data, we may be able to help our cause. And what we're finding now is that we use this racial here and quantify this. We're getting a much better correlation with symptoms. And if we were just using impedance is the dichotomous variables. So this is something that certainly on the horizon that may make itself into Chicago classifications for, you know, Now this slide represents a little bit of the information that came across when we were looking at the combination of impedance and nanometer. And what we found here is that a list trans for, uh was not seamless and really had a compartmentalized face. Um, paradigm, where you could see that when the upper stops singing opens and relaxes Theis Savage, your body essentially is in a phase of active relaxation and accommodation. Once the first option sphincter closes from the end of open to the beginning of the transition zone. What you see here is a compartmentalization where the bullets is moved to the distal esophagus. But emptying doesn't occur. And what we found with with these combined impedance monopoly studies is that Bullis emptying out of the sockets never really occurred until after the transition zone or during the stripping phase or Paracelsus. So the classic phase off a salvageable Manama tree is really from the transition zone to the contract out deceleration point, where you typically see the stripping Paracelsus and the start of bullets transit and then a phase that was really not appreciated with conventional Manama tree is this ambulatory emptying phase and at least 50% or more of the empty that occurs in supine position is during this ambulatory phase, which is not Paras topic and really represents movement of the lower sites of sphincter back to its native position within the ISAF ical gas injunction. So high resolution geometry impedance allowed us to better appreciate the interaction between the pressure events and the Ebola's transport events. And now we're getting a much better idea of what's driving symptoms and to that level, um, the group that has been working together in Australia and in Belgium together, the AIM group of which now has been expanded to incorporate many other investigators, including our group. We've been really looking at how we could leverage high resolution Manama Tree and impedance. And what the anger did initially was show that if you looked at impedance and you couple this to the pressure events, you could get a really beautiful picture of the mechanical properties of the swallowing. In particular, they were able to measure theory Interpol's pressure in a very accurate way that could actually also correlate very nicely with symptoms. So once again, thes air some of the early developments that I think we're going to see creep into a savage oh, four point Oh, that will be the next evolution of the Chicago classification. And once again, this has really been born out of the fact that the technology has improved and a better understanding and appreciation of how impedance can improve. Well, we already have in Chicago three point out. So my voice was able to hold up for the most part, and we're at the last slide, and I really think that going forward now we take these parameters the that they matter. We know that the relevant Phoenix types are helping us be better at diagnosing disorders, but now we have to see whether or not they can actually help us with outcome. Can they provide us with information that's gonna improve therapeutic decisions. But unfortunately, the problem with this approach has really been the fact that these, um I suppose users are loving it a much greater rate than our therapies were not really able to to implement new motility modifying agents because we haven't seen any. And really, the Onley evolution in terms of treatment has been poem, which is really more of just a fancy, less invasive my autumn e. So what we need to see now in the future is we need to see that we're going to develop some medicines and better appreciation of how to treat these patients. That will catch up with our evolution of diagnostics that really has been waived or or has surpassed our treatment profiles. So there's a lot more work to do, a lot of excitement in the esophagus on I think that, you know, the evolution of these techniques will still lead the way. So with that going to take another sip of my coffee and hopefully have some questions to answer and we're complete with second session. Thank you much. Thank you, Dr Panel Fino. And we do have a Siris of questions coming in from the participants. The first question comes from Ben Bryant, and he would like to know how you use repeat mana metric testing or imaging to evaluate progression of a Coll Asia culture. That's a great question. So one of the biggest problems in Ankle Asia is not dying ecology. It's actually who are the patients that a progress busy showing a long time ago that you may have patients who say they're doing great, but they have severe bowls retention on a time varying. Sava Graham and these particular patients are at risk for requiring further interventions and also progressing the end stage regulation. You know our practice now what we're doing is we're bringing people back at an interval. We typically bring them back at six months to a year at somewhere in the time period, and we do a full evaluation with high resolution geometry and impedance, and we will do time burying esophagus. But what we're finding is is that we can actually just get all of the information that we need, and we're using these new metrics Bullis flow time, a salvageable impedance, integral, the the impedance balls, height and if we see people that still continue to have an abnormal I. R P. They tend to have evidence of significant balls retention, thes air people that they were gonna watch a lot more closely. Even if they're telling us that they're completely asymptomatic, we may advocate for putting them through a pneumatic dilation. So I'm not going to send someone back to surgery, but certainly a very reasonable thing to do if someone has, you know, impedance balls, height all the way up their esophagus and they're saying that they're kind of doing okay. And the record score is a two or three. You know, we may actually advocate for sending those people for a pneumatic dilation, because once again, we do not want to see them progress, because once you dilate to a certain level, there's no turning back. So very important question. We're in the beginning stages, but I think we have a lot of nice tools that are gonna help us answer those questions very good. And our next question comes from Douglas Weinstein. He wants to be sure he heard you correctly. Dr. Panel, you know, are you saying that type to a coll Asia Onley requires Pan Asafa Jill pressurization and does not require an elevated IRP. Well, I'd like to say hi to Doug. I talk to Doug a lot over email regarding difficult cases. Yeah. I mean, I think that when you look at what we did was we perform something called the Classification and Regression Tree analysis, and it's kind of like just putting all of your data into a computer. And the computer says this is the best threshold, or this is the threshold that you need or this is the information you need to make this diagnosis. Eso When we went back and looked at this, the computer stated that we didn't really need the I r p that if you see Panesar vigil pressurization, it doesn't matter what your IRA P is Now. Where I see this classically is in the context of someone who has a very short duration Panasonic pressurization. So you see someone who has an I. R p of 10 or eight, but they have maybe a one or two second interval where their pants off your pressurization occurs, or even like a one second interval. What happens is if you remember three i r p is a four second measurement. So what happens is, is that because it's an average and it might even be zero during that other face. It doesn't really matter if you see that, Panesar. Vigil pressurization. You know that there is a transient obstruction at the a topical gastric junction in this particular patient, and it is truly path a demonic for tax regulations. So, yeah, I diagnosed people. Um, quite often it's not too commonplace, but quite often via either studies that are sent to me, I tell patients and doctors that, you know, certainly this is type two Eagle Asia. And where we really see that very obviously is is when we do an endo flip, we clearly see that their distance ability index is very abnormal below you know, two or one Andre have true type two accolade. So yeah, you heard me correctly. That and Douglas Weinstein has one additional question for you. What treatment recommendations do you give for patients with absent Paracelsus or fragmented Paracelsus E? Yeah, I get basic. Give them the same e mean for me. Those particular patients, if they are complaining of this Fraser, for instance, um, it's probably because of the Paracelsus. They may have this heightened sensation that food's getting caught or because their personal says is so severe and completely absent. Food may be caught and sitting there for quite a while. There may be a food impact. So what, I tell patients days and I think the most important feel sure. I tell them that we know what we're doing. We know what they have and that this is something that can cause your symptoms. I also tell them that unfortunately, we don't have a really effective treated for this. But when we look at people have this. If we can change your diet around, so we tell them if you could eat meat, try ground beef stakes. Gonna give you some problems? You may get caught. Eso we modify their diet. We change their their pills or their medications to formulations that arm or amenable to be taken. A za liquid, maybe three capsules taken apart with apple sauce. Dissolvable formulations are very important because a lot of these patients also have philosophical e this So if we do some basic reassurance, dietary changes change their medications around, make sure that their their upright when they're eating may be drinking a little bit of water with each swallow Most of those patients do okay. Occasionally we will have to utilize some hypnotherapy to help them kind of get around the fact that still feeling this, we're occasionally we will use a neuro modulators and, for instance, some of the mural modulators, um, that people like to use in these particular cases, um, they don't like to use the tricyclic based antidepressants because they have an anti Colin ergic effect. And they'll tend to veer more towards, um, telegram or the SSR eyes because of the lack of the anti coal energy effect. Um, once again, you have to really be thoughtful with the patient and reassure the patient. And it really does require a lot of, you know, just, um, bedside kind of just reassurance. And and that's how I treat him. I really feel that Ragland, Don Paragon and Beth, uh, Muthanna call their side effect. Profile really is too significant in terms of the really limited benefits that you have for those particular medicines. So I think it's unreasonable to try those medicines. No, but once again, if they're really not making profound effect and the patient can't live without them. I think you got to get rid of them because there's really not a lot of good data to support their utilization. And now we have an I. R P related question from May Tora Gaza. She would like to know what is the correct cut off value to use with sandhill equipment. Yeah, So I think that when you look at that in the unis sensor, you know, I thought maybe there was gonna be more of a pathologic question, but I want to show you this. You know what happens through here is that you got to remember that theological gastric junction. When it's relaxed, it's still closed. So when that catheter is sitting in the historical gastric junction, depending on what type of sensor that ISS, whether it's circumferential unit, directional, the type of sensor, whether it's tax array, a standard string gauge transducer, which whichever one it's gonna have a different signature through the historical gastric junction. So what we found was was that the upper limit of normal using the Santel sensor was around 2021 in our hands, and when we looked at the actual data and that particular center time. So I think that, you know, that's important, because if someone has an I. R. P of 16 or 17, that's actually normal when you're using the Heck Sandals system and it doesn't mean that there is any difference there, it's just you have to use that because if you look at what the absolute or the upper limit of normal was for the dense leave and the water profuse systems, they were anywhere from 6 to 8 millimeters per American. So the I R P for the Sierra system, which is now evolved to the comedian trying system, was 15. That was much higher than what we typically use, even if we used the 12 millimeter per mercury upper limit of normal. So you just have to be very specific for the hardware and system that you're using. And if you use that you're not gonna make very many mistakes, our next question relates to the hyper contract. I'll esophagus. What's your experience with using Botox injections at the level of the L es versus distal esophagus? Eso You know, there was a study from the group MoveOn, which was a randomized trialing um that still some benefit using Botox and distal esophagus and patients with spasm on may be these hyper contract of disorders. Well, unfortunately not found that in our in our practice, and I have to say that initially with hyper contract disorders, I was very gung ho of using endoscopic. Lee placed talks through the entire soft your body and the J Way had a couple of pages respond, but they always kind of occurred, and it never worked in. In addition, injecting Botox in the body of Sophocles there's a little bit dangerous because, you know, it's a little bit thinner wall and gotta be careful. There have been reports of meetings, tinnitus, and overall, I really have not been that impressed with that particular therapy. So we really abandoned Thea. The reason why we abandoned it is because we did find that in some patients poem with a tailored my autumn E from the transitions on all the way down the esophagus actually worked. And if you get kept doing repetitive Botox injections, you would probably obscure the plane for the surgeon and the endoscopy. Us. Get through the sub mucosal down to the must. So in our practice now we've kind of gone away from that. Now, That being said, you know there are instances where I will use Botox. So they have been equivocal case where, you know, the patient may have some risk surgical risks if we need to get outflow obstruction. Or maybe they have a jack hammer pattern with evidence of some mild borderline I. R p. We do an endoscopic ultrasound, and it's negative. There is no mass. There's no stricture in those particular patients I may inject. Some both talks here. E remember, you're gonna have to go back and stick to 12 months and many of these patients. So our standard algorithm is that we treat spastic motor disorders and hyper contract out disorders with smooth muscle relaxants. First, if that doesn't work, then we contemplating poem and a tailored approach, and we've had some good not a huge Siri's, but enough that we were on the verge of starting up a randomized controlled trial for tailored poem versus standard poem in type vehicle Asia. Next question aren't an ambrosia or Lambros. I'm sorry. I would like to ask when you see really prominent cardiac contractions that are transmitted all the way to the E g J. Do you classify that as an e g J obstruction or merely is artifact? Great question. So, for instance, when you can see here in this particular slide, it's actually gonna have you. You can see a pretty significant vascular signal here, and you could see that it's different than the cruel contraction. It's at a rate, and if you look at it probably a raid, you know, of anywhere from 80 toe 85. And when you look at that particular single, there are instances, and this is really where impedance is very helpful. So you may see that this vascular signal down here, even if it's closer, that you may see bullets retention occur beyond that. And it's suggesting that that's really an obstruction so that when you pre gets back thio level issue nurse that's performing excess what they use. The patient protection because sometimes you get stronger, faster signal in my position. But when you put the patient in your profession, it completely goto. Our normal district includes, however, if that persists in the upright position or during positional changes, that may be a true obstruction and in those particular patients. We typically send them for an endoscopic ultrasound. If we document that this is related to their they ordered some people. We've We've diagnosed aortic aneurysms in this particular instances. Cardio, Magaly, You know, those particular examples will at least make the diagnosis of pseudo eaglets. You're related to a vascular issue and depending on what the treatment options are, I mean, obviously, we're not gonna have someone undergo Ah, heart transplant if they have a dilated cardiomyopathy for this. But eventually, you know, if that if they do have an aortic aneurysm, we've had people treated and have their Eric aneurysms treated. Who had this patterns all. So So. Certainly an important observation is something that can help you. But many of those patients who are too sick to have something done, you know, what we'll do is we'll once again, soft food watch solid foods, reassurance and so forth. And Dr Panel Fino, this will be our final question because we're running out of time. This is another question from Douglas Weinstein. He would like to know what's the correct way to perform the multiple rapid swallow maneuver. Yeah, good question. So although it is not a priority and, you know, it's It's not a marker of a poor quality study. Most people believe that we should do some form of rapid swallow multiple, rapid swallow. So what we typically like to do is we like to actually perform this, Andi. Once again, it matters how the patient can tolerate this. Typically, what we try to dio is that the end of swallow in the upright position we actually have a syringe. And what we have is the syringe that is capable of delivering five mobilized is and they don't have to be exact what we try to deliver those bulletins at 1 to 2 second interval so the patient can swallow and what you're looking at, her two distinct things you're looking at dig lucrative inhibition, meaning that the swallow the next swallow will be inhibited and you won't see any Paracelsus. And the second thing you're looking at is at the end of the fifth swallow whether or not cursed all sizes augment because we can see instances where there is very weak or ineffective assumption motility, where when you do this, all of a sudden they have this beautifully augmented normal end personal tick event. So that's typically how we do this. Now There's some patients who just cannot time, they're swallow appropriately, and in those particular instances, we may allow the patient with a straw to sip, swallow, sip, swallow, sip, swallow, sip, swallow. Um, once again, that could be a little bit, um, difficult in terms of getting into that interval, because once you start to get beyond two seconds, then you'll start to see the deluded escape and you'll see these propagation of these contractions, and you really don't want to do that. Another thing that we also do is that at the end of the swallow, we have the patient swallow 200 ccs of saline, a mixture of sailing. And that's how we do our our typical impedance balls height, which is very similar to surrogate for the time bearing sophomore. So that's how we do it in our lab. Thank you, Dr Panel Fino, and that concludes our webinar. On behalf of sandhill Scientific, I would like to thank everyone for participating and for the great question and answer period for your colleagues who missed this event, please pass along to them that as of Friday they could go to the sandhill scientific website, www dot sand hillside dot com, And they can view this webinar in total at any time thereafter. Thanks everyone for participating and good day. Thank you very much. Created by Related Presenters John Pandolfino, MD Chief of Gastroenterology and Hepatology in the Department of MedicineHans Popper ProfessorProfessor of Medicine (Gastroenterology and Hepatology) View full profile
