Chapters Transcript Video HRiM Case Study Review Presented by John E. Pandolfino MD, MSCI, Northwestern Memorial Hospital, Chicago, IL. um, I know many of you. Probably not familiar with the zebu system. Um, and what I'd like to dio today is kind of take you through some of this, um, in terms of this new software package and also talk a little bit of how we're using it here in Northwestern on DWhite we've been excited about in terms of, um, some of the features on the software that I think are extremely important and very user friendly. I think that some of the the development of this technology in this analysis methodology really incorporated a lot of feedback from people using this and in particular me, um, you know, things that I liked about other systems, things that I didn't like about other systems that I thought were very helpful. Andi, I think that, you know, we get a lot of questions about, you know, landmarks and a lot of questions about some of the metrics. And I just kind of want to take you through a few standard cases, um, Thio to begin with, and then maybe a couple of ah, little bit mawr e guess not standard cases and primary motor abnormalities. So, unfortunately, can't look at the Webcam directly and the screen at the same time. So we'll look like I'm not looking at the audience. I'm looking at the best top. But, you know, I think that that's that's gonna be simple. I'll have toe deal with and you'll have to deal with, uh and I hope it's not too disconcerting for everybody. So this is obviously the new system. This is what you see when you open the study and I'm gonna take you from the start. So basically, here you have the start, uh, with patient management, and this is really where you'll have all your studies list and I'm gonna open up this study here, which we will evaluate. And this is essentially a nice study because it's it's, as you can see, just from opening the study, there is definitely Paris. False is look somewhat normal, but there might be some small little abnormalities that we might have to contend with. This is a simultaneous high resolution Manama tree with impedance on DWhite. I want to take you through is a top toolbar here, and you can kind of see that you can change the color scale based on this and most of us would probably want the colors is as deep on dark as we um, with like and here we can do that. We could do this also with impedance. You know, you can take it away completely, and you could bring it in so that you can visualize especially liquid signal. Um, you know, in a very high detail, you can also, if you'd like over lie tracings, which I think is also very nice feature. And I always tell people I still like the impedance tracings when I'm doing ah, lot of the postprandial studies especially. I'm thinking about reflux and and ruling out patients with rumination syndrome from specifically looking at people with super gas belching I like toe have the tracings over laid so you could see up here on the top toolbar. You know, you can play around with the colors. You can play around with the colors of the ice of contour and P events. You can also overlay either the pressure wave form or the impedance wave form. And I think that's something that I do like to do, especially when I'm looking at the postprandial studies. Then, of course, one of the features that I like most about the system is really the metrics. When you click the magnifying glass up here, what you see is this something. I'm gonna just move things up here and you can see study summary here, pattern classifications. So, um, we'll start like I would start with any kind of study here, and I would basically go to the initial landmark, and this is obviously the resting phase. Expand this out as much, but this should be enough to get us where we wanted. You want to get at least three respiratory cycles here, and I'm gonna take away some of the impedance here for now, three respiratory cycles where you actually have no evidence of swallowing. So when you look at this particular area here, this is a pretty good marker of an area where there's not a lot of parasol Tic activity. Expand this out a little bit. I'm gonna get rid of the tracings. So this is what it would look like if I was just looking at a real time and I would set up are landmarks here and you can see you can look at the length of the upper sphincter and that immediately calculates And I'm going toe, basically make sure the length of my upper sphincter is correct. And I think that's pretty reasonable. I usually tell people, you know, you just need to be comfortable with the landmarks in terms of the spatial domain and timing. Um, you know, if you turn off by a millimeter or so, it's not gonna change anything dramatically. What's interesting about this particular case is that there is a little honey here. So this is a nice example to start with, because what this will allow us to do is actually show you where I would put our El Es marker. So I believe our Elias is right about here. Scroll this back up. And just like anything else when you do this, if you don't get the landmarks right, a lot of your automated analysis is gonna be wrong. So you really want to make sure you spend a little bit of time um, doing this and here, Obviously, I have my Elias, But given the fact that attorney and we're bringing my e g j measurement to the distal aspects of the curl diaphragm and this way, you can kind of get a sense as to where the domains will be for the I r p and certainly through the proximal and distal order for the d. C. I. So now that I've got my landmark set, Um, what's great is is you can see here right here in the measurement, um, metrics or measurement metrics are resting. You can basically see all of my landmarks demarcated in terms of upper sinker length, the distance. You know, where the practical pressure inversion point is, the proximal Elias, you know, distal ass. All of my measurements are made. They even give you a distal baseline, um, impedance measurement there, which is about 641 homes. Not something that I would typically look at just yet. Um And then, of course, we get some strength through measurements. Here's the upper sphincter 228. And then here you can see the high pressure zone. And as you would expect in someone with a small hernia where the pressure pressure inversion point is at the cruel diaphragm, you can clearly see that the Elias pressure in this particular example um, mid respiratory is negative and end expert Torrey eyes negative. So you're actually seeing here, Um, over this period of time, these negative inter Thor ASIC pressures here. So you know, once again, this is a person who has a hernia at resting. You know, the sinker is quite week. Someone probably he's gonna have a little bit of reflux. And once again, when you don't see the strength you hear, the best way to analyze this is to look at the after contraction to localize where you believe the strength there will be. And once again, I think that this is a nice example of how we would do that. So now that I have my landmarks demarcated pretty well here, I was gonna maybe fine tune that a little bit here. And what you see is the top of the Elias. Really, Um, coincides with the top of the E g. J. And it moves in sync with that when I make that particular move here. So you can see we get these pressures and then we're really able to start our evaluation here and just looking at the first swallow here, you can see that the the value system, um, is basically giving us a space time domain for D. C. I the beginning of the swallowing, and I hope everyone could see my my marker here. So this top boxes that space time domain for D. C. Calculation this line here with this little circle here is really going to give us the start of this follow to the CDP or an estimate of where the CBP is. I'll tell you, you know, the CDP measurement is something that has had a lot of, um uh, issues. In terms of not being very clear is toe where it can make that measurement. Um, sometimes it's very easy to figure out. And I think this is an example where the CDP is not all that straightforward. You can see that the velocity of the contract away from here is pretty good, and it may slow right about here. So if I were to actually take this, I would probably move the CBP to right about there. And that does correlate pretty well with the offset of contraction here in the back. And that's one of the other small little details I use when I'm trying to find the contract. How deceleration point. So now we have started to swallow, which is usually pretty easy where I believe the CDP should be. Where there is a slight changing the overall velocity, remembering once again that it has to be within 2 to 3 centimeters of the proximal aspect of the Elias many times with a hernia, it is much closer to the proximal aspect of the L. A s on did in this particular example that is true. And you can see here is the lower Southdale center. This is approximate aspect, and almost core corresponds directly to that. Because there's not a lot of this actual movement when there is a hernia, because there is laxity of the free no softy ligament on there really isn't this pulling of the sphincter up into the chest and many of these patients because the sinkers already moved into the chest. So there's, you know, the CDP is is obviously modulated a little bit about by shortening and the elongation and repositioning of the sector within the hydro canal. And in this example, obviously the sector never goes back to its native position. Within the hiatus. Andi once again remains up here, so you can see nice example of a small Heidel hernia, Um, landmark Set. This is basically the box that will give us the I R. P. And if you said this was maybe a little bit too long and you wanted to just shorten this up a little bit, I wouldn't disagree with you. You can shorten that up to stop Tad here once again to move it out of the Gasser port. And I think that you have really good landmarks here. It doesn't, You know, the one of things about the d. C. I box is that this particular box? It doesn't really matter when you look at this where it starts and finishes, but I like to keep it right around the transition zone and then really, where the offset of the contraction is. And I think that's a pretty reasonable space time domain for the calculation. I think that the it doesn't matter once again for the measurement of the IRP. Um, where you finish the contraction as long as it does intersect here. And whether I bring this all the way back here is not gonna change the measurement of the I r. P. Overall. So looking here we're gonna go back up to our measurement metrics here. It's going to tell us that the I R P from this liquid swallow is three millimeters per mercury. The distal agency is 8.3 seconds and the D. C here is 216 millimeters per mercury per second per centimeter, which would be on the range of ineffective. Now many people argue and debate whether you know, there's this nuance between fragment that swallows and and whether or not you're gonna use the term ineffective, weak. And I think that the crux of this is is that if there is a defect in the parasol tick wavefront using the 30 millimeter per Mercury Isil barrack contour of five centimeters, a greater then this is a fragment that swallow, if there isn't in the D. C, is less than 4 50. That's a week swallow, which we would consider it an ineffective swallow. But a fragmented swallow is still an effective, and when we calculate and look for ineffective esophageal motility, I think it's really important to be a little bit more detail oriented, describing where the fragment is, whether it's in the proximal aspect where the distal aspect because then if it's an approximate last, behaves more like a transition zone defect. If it's an additional, uh, second or third segment here than it would behave more like an ineffective swallow that we would see with poor Bolas clearance and b'more likely associated with reflux disease. So here you see very nice measurements. Um, you know, we don't really use all that much the contract out front philosophy. Um, this is really just giving you the C B is giving you the pattern. Once again, we're considering week. Um, it could have to be failed hyper contract. I'll normal a week. In this particular case, it is considered weak because the value is below 4. 50. And in terms of the contract, how pattern it appears to be overall intact. You do see a 20 millimeter per mercury Essabar Contour. That is pretty seamless throughout this swallow here. And there's some small defects in the 30 millimeter, primarily. So I think the computer is getting this right. Um, on this is that this is a week and tax swallow and essentially, um, ineffective is what we would qualify this as in terms of conventional I mean, I'm not really gonna look too much at this. You can see that this would be something that might be called effective if you were looking at, you know, the 30 millimeter per mercury threshold at three and eight centimeters above, um, the Asafa Gastric junction. Once again, this this is a nice example where there's a little bit of lack of correlation and concordance between convincing Manama tree and the E p T. Classifications of weak or ineffective swallows. Um, and you can see and we're gonna go through each one of these swallows really quick. Um, as I mentioned and I want everybody to look at the measurement profile here because we'll show you is that when I changes D c I box, you can see that the D. C. I hear is 186. If I move this over Thio here, where it's probably pretty reasonable, you could see that doesn't even change the measurement. A tall So once again, Once you get to that level, it's really not all that important. You can see here. I'm gonna look at the just Elaine c. I probably would put that right about here, and once again, I think that this is a nice example where the hiatus hernia does affect the contract of the acceleration point and the CDP is always much closer The proximal aspect of the L. A s in that particular instance. But, you know, the distal agency once again is 8.1 seconds in the normal range, and the i r P appears to be in the normal range, so this would be a week and tax swallow. Um, you get into the point where there might be a little bit of a fragment here, but but not quite. And I think that when we go through each one of these swabs, I'm not gonna change all the boxes. But you can see this. This particular swallow certainly looks a lot more normal. The D. C here is 873. Um, just Elaine C, which I would probably put down here, um, 7.6 to 8 point to now not really changed too much. If I play around with the I. R. P. Still think it's good enough it's still gonna be within the normal range, So this would be a nice normal in tax while so what you're seeing here in this particular swallow in this particular study is the patient who is presenting with reflux symptoms. Who is, uh, potentially going to undergo a funding application s Oh, this person is being referred, actually for a lynx procedure. Andi, this would be someone who you know, we would speculate. Asato, what they're dysplasia risk would be on dso. Certainly the surgeons like to hear whether or not the Pacers have intact Paracelsus ineffective Paracelsus or absent contract Il ity where we really get into the difficult scenario is in the issues of whether or not this person with ineffective assumption utilities gonna develop this Basia And I think that's very controversial. I'll tell you what, how I usually assess that. So if I were looking at this patient and looking at these swallows based on 10 swallows, you can see here that this is a nice example of absent contract Il ity. The D. C. I is essentially here 1 62 but that is probably most likely related to a lot of this activity that it's getting from the stinker here. It's really less than 100 which is essentially a failed swallow. You can see the I. R. P here once again, along with the fact that this is a good patient is still very low and just the lanes here I wouldn't even calculate, to be honest in the context of this absent fails well, so here you're having a mixture of swallows that air somewhat intact, weak or absent. So this is This is an interesting case because how I would essentially address this person going back to study metrics. So here's resting. Here's the liquid swallow. You can see that based on study metrics. This is where they give you the summary Of the 10 swallows, 80% of these patients 80% of the swallows in this particular patient are ineffective. 20 percent had a normal D C. I 60% would be considered weak, 20% would be failed and then 80% of these would be intact. So the mean D C is in within the week range. So this would be someone who I would tell the surgeon. Based on this, this is not severe Paris topic dysfunction in terms of ineffective, this option motility and I would be comfortable sending this person for an anti reflux procedure. I would always caution the surgeon to still let the patient know that the risk of this Fraser would be higher. Um, in this particular scenario, then it would be with someone with intact Paracelsus. But this certainly is not a contra indication. Um, Teoh a evaluation and eventual referral for funding, application or links procedure. Now, one of the things that I would certainly do, though, when I am evaluating these particular patients and this is something that, you know, I do not based on on any data that I have, but more on my clinical impression is that this is where I really think that assessing impedance is important. So here we have, you know, a nice example of talking the isil contour where you can clearly see that in this particular swallow, despite the fact that this is a week swallow, there seems to be pretty good bowlers transport. So this is someone who A to this particular junction with hypertensive el es can empty this office. So in this particular example, this swallow appears to be cleared quite well. And as I scroll through now with the impedance said at this particular level, I could see that there is certainly some mid Asafa deal in proximal escape here. Not dramatic, but certainly some where there might be some impaired bowls, transit. But this looks like some minute amount of bullets would be retained. And this would be easily cleared with the second dry swallow, or even a a second wet swallow, as you can see here, a nice in tax swallow. Um, once again, beautiful bolas clearance. And for the most part, I feel pretty comfortable that the bowl is clearance on this patient. Looks pretty good. And so sorry. I didn't need to make that in this particular example to see. Certainly there is a bowl of transit abnormality. Um, this one, this continues and here is a little bit weakness, so you can see that there are some swallows that you have. Abnormal bowl is transit, but for the most part, this patient can generate, and this is the pen swallowed decent para styles is where liquid Bullis transit would be pretty good. Um, in the context of a hernia. So this is someone who I wouldn't say has a contra indication to fund application based on this, But I certainly would, um uh, pre operatively discuss this with the patients say that their risk for this page is a little bit higher because they're Paracelsus is not perfect. But certainly they could go ahead and get this and we could deal with the ramifications a zit occur. This is someone I think we're a lynx procedure, you know, and I don't have a lot of experience with links just yet, but we're theoretically, I could see a lynx procedure being a good option because once again, if if they do develop pretty significant this phase, you can always take the links. Um, magnetic ring the NSA, the magnetic sphincter augmentation device out of the esophagus on bring the patient back to their native state without having to dio a pneumatic dilation or trying to take down the rap again. So once again, I think this is a nice example of a mixture of ineffective and normal purse topic sequences with some absent decent bowlers. Transit and ability. Thio have normal pursed analysis and cleared Ebola's. Now there's been some discussion whether or not um taking these particular cases and looking at multiple rapid swallows and the ability of the savage your body to augment. For instance, if you see that after multiple rapid swallows that the pursed optic wave front and the vigor will change to augment and you know there's a lot of debate on the ratios. But if you see ah, seemingly normal purse topic wavefront after multiple rapid swallows, that could also give you some degree of comfort ast to whether or not the patient will do better or we'll do okay with a anti reflux procedure. So I think this is a nice study Thio to sit, and I'm I'm not seeing any questions being typed in on the chat box, so I'll assume that everybody kind of is in line with what I'm discussing here. But certainly we could talk about it when we move further down along on some other cases. So with that, I certainly will certainly be open to some challenges of whether or not other people would have sent this patient for a fund publication or thought that this was contraindicated. But I sent many patients with this particular pattern for funding application with some reassurance and and guidance, and they've done quite well. So let's look at another study and once again I think you know, always actually go to this other study here first, right? I think once again what I like very much about the way the data is presented with the new Santel system, Samuel Software is it's really organized in a very efficient matter so that you really see the swallows below so I can visualize the resting period and at least the 10 swallows in a snapshot. And really, I could just look at this right now and make that diagnosis of what's going on here. And it also allows you to Tom go back and forth between swallows of interest, which I think is also very interesting on dim my mind something that makes this a lot more user friendly. Um, but for the intensive purposes of an educational, um, endeavor here, I'm gonna go through what I would typically do with my landmarks. So here's the resting stage. You can see I get three respiratory events here. Expand that a little bit. I think that the markers that air set here, you know, you can see that there really is no significant hiatus Hernia. I think that these are all very good. The upper sink ter the lower sink and a lot of people discount the upper. Think they don't look at that. But you gotta remember that sometimes Thea Percenter is utilized as a marker of where the transition zone should be and the proximal border of the D. C I. Space time domain for calculation of the D. C. I. So don't skimp on the he U S landmarks because they can be very important. So here I can look at our landmarks, um, but hit our measurement box. We're gonna look at the measurement metrics and it's calculating now and the study metrics on, then I'll even this particular I'm gonna scroll up here a little bit so that you can see so you can see the computer already has made the diagnosis for you here in terms of the study's summary pattern classifications hyper contract. I'll I would certainly agree with that. Um, if you look at the resting measurements, you can see that the L. E s pressure here 38 expert torrey maybe a little bit lower five millimeters per mercury. But once again, I think that this is reference to Gasol pressure on DSO. Certainly you can clearly see that that this is probably someone is grossly intact. Uh, e g j. But what do you things that you're gonna really see when we look at the individual swallows here? Do you magnify this a little bit? And I'm gonna just for the intensive purposes of this and take away the impedance, you can see that there is certainly some degree of shortening that is occurring here. Um, in this particular swallow for the point where you can see some separation of the lower stop the center at various portions of the swallow. Um, in terms of the curl diet from here. So once again, you can see the box here. If I were to do this myself and manually, I would probably scroll this back here. It's not gonna really matter where you do this. I think that some people may say, You know, John, I think that the CDP is here on, Do you know once again, I don't think it's gonna matter, because it's still essentially within the normal range. And this is a propagating swallow. Once you get above 5.5 6 seconds, it doesn't really matter what the lanes is and I think that this is going to give us a nice example. What you can see here, though, is that the IRA P is slightly elevated. But remember, with Santel system, the upper limit of normal is around 20. So this is just right at that cost. You can see that this delay agency interval is 5.8 seconds and the D. C. I s 11,000 once again consistent with a pretty significant abnormality and one of the things about jackhammers office that although you know the criteria, suggests that we need to have a least two swallows. And remember in Chicago 2.0, it was only one swallow many patients who truly have really jackhammer not just kind of this art, if actual maybe one or two swallow abnormality really have abnormalities and almost all of the swallows. So it's very interesting when you see this particular pattern. And I really like the snapshots on the bottom because they really give you a flavor of the study. A nice example in my mind of jackhammer and you can clearly see that this particular pattern here, you know, if I look at the d. C and this 13,000 pretty significant with a very mild borderline. Now it's very important when you see Jack Hammer toe always aggressively rule out any D j outflow obstruction. Because thio become extremely hyper push, the bowl is through an obstruction or a fixed obstruction. So once again, very important to always look at that. In this particular example, I'm gonna look at the liquid swallows here just to get the measurements and study metrics. You can see the normal B C I 10 hyper contract all 90 money of these air intact, demeaning, and I R P is below 20. So not really a significant e g outflow obstruction in this particular patient. And this is someone that I would consider eyes having a primary motor abnormality with a jackhammer pattern that likely is a significant primary motor and them out. This is not a manifestation of e d. J outflow obstruction. This is something that will probably require treatment of the Khyber Contract of Disorder in order to improve the presenting symptoms. So with that, this is a pretty straightforward study. I love the fact that all that swallows here, you can clearly see here that this swallow is persisting. Um, D c I was red initially, 11,000, but you can see here as we scroll the south is gonna goto 28,000 Clearly abnormal. So this is someone who I think would benefit from some type of therapy focused on reducing the contract. How bigger with that's medical therapy with either nitrates, calcium channel blocker or anti Colin Ergic. I think patients who have significant chest pain um, you know, certainly low does t. C. A s can also be very beneficial in some of these patients on Sometimes we use that as a complementary, um, medical management in some of the patients who continue of chest pain with particular pattern will try them on nitrates and potentially add a T c a. So once again thes patients, we typically start with medical management using a combination of nitrates and potentially something of an anti Colin ergic effect. If those don't work, then we'll move to the higher level Smooth muscle relaxants like the five I'm fossil brasseries inhibitors like So the NFL, Andi. Once again, if those fail than these air, potentially the patients that we will send for poem procedure now at our institution, and we're getting a little bit more experience with poem in this particular jackhammer pattern. And I think as long as you define the patients appropriately, you focus on the theme the de de de outflow obstruction ruling that out. You can't have good outcomes with this particular approach. So this is a very nice example of jackhammer once again persists. You can see the nice thing here is is that it's in every single swallow. And once again, you can make the diagnosis clearly by just looking at a snapshot on the bottom here on the computer. Rightly so, um, diagnosis patient with a hyper contract, I'll swallow. So I'm looking at the Changle. All right. I think we have a few questions, and Ban is asking me to stop here. So what we hoping up for questions? Hi, Dr Panda Fino. A few questions came out of the first case study that you presented with the ineffective swallows. The first. The first question was, Do you ever recommend a to pay funding application instead of a nissen? And in what cases? Sure. So I think, um, if if this patient had no evidence of untaxed parasol tick sequence. So, you know, I'll just pull it up. Are we here? So I'm just gonna expand out here so that we can look at this on, say, for instance, all of swallows look like this. You know, certainly I'd be very nervous that this person is gonna have a very bad outcome. All right, So this is someone who I would probably say if all those swabs were essentially looking like this. With poor bowls, transit essentially almost fails. This is someone I wouldn't send for anything if swallows all looked more like this, You know, and there's good bowls transit. I tell them that they really don't have toe, you know, augment or or you know, uh, change any of the approach here, I would send them for whatever. But when there is significant, when when almost all of the swallows are ineffective or fragmented, there's no evidence of normal Paracelsus. Um, there's no augmentation with multiple rapid swallow. In those particular instances, I will encourage a partial rap or an interior rap to the surgeon, and they usually go along with that. I think that that's a decent idea. I think once again, the data is controversial. and somewhat conflicting of whether or not that does really change things. But I think theoretically, it allows you to posture with the patient that, you know, you're you're worried about the dysplasia risk. They need the operation. You're going to do everything in your power to prevent, um, this phase in which they may be a slight increased risk. And you really don't lose all that much in terms of the anti reflux control. So I think that's kind of how it is. But, you know, this is a little bit more where this is more art than, you know, science. Because you just have to sometimes make a decision that you don't have great data for based on your gestalt. And I think that that's typically what I wanted. Doing okay on this same study. Swallow number nine. What is the Pan Asafa Jill pressurization scene there? Sorry. What was that on swallow number nine. There's pressurization right here. Yes. What? That's just Yeah, okay. And let's see, when you see this short burst from top to bottom, going from the stomach all the way up, that is typically a cough. That's kind of associate, and people tend Thio kind of do that when they swallow a little bit, they might kind of cough a little bit. He's got a couple of them or maybe one other one on swallowing before the swallow, actually. Okay, back to your jackhammer study. Mhm, Um, with a borderline i AARP and jackhammer pressures in the esophagus. How much would you use the impedance to exclude it being a disorder of e g J outflow? Well, I mean, you know, you can look at Bullis Transit, and actually, we couldn't do that here. No quick expanded here. So now we have our impedance here. Now, the one question is, is that, you know, I don't know that we really have a great measurement of Interpol's pressure available right now. I think that many of them, you know, measurements that we do utilize focus really on the isil, Um, the Isil Barrett Contour tool and assessing whether or not there is this compartmentalization here. You can clearly see here, though, that in this particular swallow, you know the intervals pressure is not all that high here. You don't really see a significant Interpol's pressure here. And there is decent bowls transit, so yeah, Certainly if you see that there is retrograde escape through a hyper contract, I'll swallow. That would suggest that there is an obstruction. And I do think that we do need better metrics. You know, the I. R. P is a good metric for looking at whether or not the the sector has relaxed, but it doesn't really give you a great idea of whether or not the soccer gastric junction is wide open and accommodating the Bullis. Um, certainly in this particular example, I think that this study, you know, if you look here, there's a little bit of retrograde escape through the mid body. Um, here, you know, there there's nothing that's gonna really go backwards through here. I think a lot of this is just from the top of the swallow. Um, this is something that I'm not too concerned with in terms of, you know, the overall obstruction here. But if there was something that you were worried about here and I think I am a very low threshold now, once again, I probably use the flip device quite often in this patient population. On did usually use that as my benchmark for whether or not there truly is an obstruction. But if you know, if you don't have to flip, Certainly getting a barium Asafa Graham with a 12.5 millimeter tablet is something that's reasonable. And in these patients, if you wanna, uh, evaluate them for an obstruction or subtle destruction. But this is someone that I think it's probably okay, this is more likely just a standard jackhammer pattern. Remember that the upper limit of normal, um, in this particular system is around 20. Um, and if you look at the liquid swallows here, you know the meaning. I R P is 18, so it's it's still within normal range, so I wouldn't be too concerned. Okay. Two rather related questions. E g j outflow obstruction, Manama tree. What? It would be the definition you just touched on the median I r. P s or anything else that would go into that. So it's a great question. I think that when we're looking at you, do the outflow obstruction were over diagnosing this. I think that that's mostly a marker of the fact that the sensors are great in the esophageal body. But through the soccer gastric junction, you know, there's a lot of asymmetry. There's a lot of contact. Um, there's a lot of mobility. So you run into this scenario where many of these patients and I'm not I don't know exactly. Depends on what your referral? Um, uh, profile looks like. But many of these patients just have an artifact. In addition, there are vascular signals, cardiac signals that can be transmitted through the use optical gas injunction that could also raise the IRP. So what I typically do is I typically look at a few features. One is, I always change the position. So if the if the elevated IRP remains elevated in both the PSA pine and the upright position, it's most likely not an artifact. Um, and it can, even even if it's a vascular, the fact that even if it's a vaster signal, it may actually be a vascular compression. That's riel, Um, so if it persists in both the upright and supine position, you know if it is greater than and using five millimeters per mercury. So so if it's greater than 20 using the Manus can system or greater than 25 with the Santos system, then that makes me a little bit more comfortable that it's true. E g out for obstruction Andi Once again, I think that many of these patients were borderline numbers. If I don't think it's an artifact based on the fact that it resolves in the positional change, you know that those are the patients that I will get a flip study on to look and see whether or not there truly is a restriction at the ISAF gastric junction. So yes, I do think we are over calling a lot of this. We do have some other metrics that are gonna combine impedance with my knowledge is something called the bullets flow time, which may also help us refine our ability to define true e g outflow obstruction from some of these artifacts. But it is a difficult issue. Thank you. If you have a moment before you go on to another case, Another question related is, can you share with us how you treat cases of Asafa Jewel outflow obstruction in the absence of a hiatus? Hernia. So sorry the last part of that if there were no hiatus hernia. But you saw outflow obstruction. How would you treat that? So if there was no Heidel, honey And I saw an outflow trucks. And you're just talking, in general in general terms. Or give us an example that maybe you've run across. So I mean, if if I saw someone had e g outflow pattern, I believe that it was Riel. Um, and I was assessing the first thing that I would always do, and there was no hernia noted here. The first thing I would always do is is make sure the patient had a careful industry. And if I wasn't confident that they had a careful industry, I would repeat the in Boston. I can't tell you how many times I've had patients come in for e d. J outflow obstruction were allowed illegal Asia. I go down there and there's a mechanical obstruction. In fact, we had a recent case where the patient actually had a chance. Um, and this was probably, in our minds pretty obvious. Andi, once again, you know, this is someone who came and referred for this. So we have a very low threshold for getting endoscopic ultrasound in these patients to, um to rule out mechanical extrinsic process. And if that's negative, and we truly believe that this is Mawr Kin to and involving escalation. We treat them as if they have a village. Now, this may be one of the times where an impaired trial of Botox may not be unreasonable. I think money these patients are early on on. Do you know I don't know that you know the Botox administration, if you just do one time is gonna obscure the plane. Um, if you decide to do calm or hell of my anatomy. But certainly we use endoscopic ultrasound to stratify patients into Ankle Asia and evolution or mechanical obstruction. Obviously, if it's a mechanical obstruction, we will evaluated and treated, you know, based on what it is, whether it's obviously it's canceled with you. With that, um, if it's an extrinsic vascular issue, we'll see if there's any vascular. We did have a patient who came in at a a thoracic aneurysm that was causing a su a glacier pattern. That patient underwent Andi aortic aneurysm repair on board. The sue escalation pattern resolved that the patient had a very rocky postoperative course eventually did. Okay, but once again, not not a common scenario. Thank you. I think that will be all the questions for now if you had another case you wanted to review Yeah, I mean, I think See, I'm just gonna check the chap here, okay? No new cases. Alright, Alright, I'll pull up this other case here. So one of the things that I think is extremely important when doing Manama Tree in the era of high resolution nanometer and patients presenting is remembering that you know, these technologies, um you know are very good at ruling in diseases. But they're also very good at ruling out. So you know when people present with aphasia and you're performing high resolution Manama tree, I think that when patients have borderline abnormalities, it's extremely important. You know, Thio not over call or put too much emphasis in those borderline abnormalities in and of themselves when you're dealing with the specific complaint of this Feige. Because then, um, those particular patients tend to have something else going on. Whether they heightened visceral sensitivity or underlying GERD Um it's extremely important to keep that in mind. And I think high resolution Anoma Tree has allowed us to really look for those particular issues and really do a much better job at truly defining patients is having function of this phaser where will wind up treating them as if they have more of a functional battle to sort of in a mechanical obstruction. So there's going to show this particular study because I think that this is a very nice study once again and going back to where you're starting to see a very subtle abnormality that could certainly, um, give you an idea that there might be an obstruction here. So this is someone. And if you look at this final, we don't have a little bit of time here. Um, this is obviously someone stole this over a little bit too much. When you look at this particular swallow here looks pretty normal in terms of para styluses. I'm going to get a couple measurements here as a calculating. You see, there's a little bit of honey here, D c. I looks pretty normal. Distal agency interval. What's pretty normal? I think that's a pretty good estimate where it should be. Um, d c I s normal. This looks like a normal impact swallow. But there's a very subtle feature here that you need to keep in mind. Is that this compartmentalized pressure here is a little bit abnormal and you can see the shortening of the center here. And this is someone actually who may have a very subtle obstruction that may be missed with the IRP. If you're not using the appropriate space time Domain box and e sleeve Elektronik sleeve. So here. Now you can see if I take this over here a little bit, But in this area here, there certainly is a little bit of a compartmentalized pressure with this particular girl center here. Although there does appear to be pretty decent. Relax ation later on, probably after a lot of the Bolas has squeezed through here. So you can see that the Bolasie's is able to kind of squeeze through here. So here there does appear to be this this adjunct finding of slight compartmentalized pressurization. And this is the pattern that you would typically see in someone with GERD and a subtle peptic structure. Um, once again, a little bit of this early compartmentalization is the bowls is being squeezed through a little bit of this title attorney here. And this is someone who if you did a burying Asafa Graham with a 12.5 millimeter baron tablet, they would have hang up at the lower sophomore center despite the fact that during the dossier you may have missed this S o. This is a nice complimentary feature that kind of goes along the lines of the previous patient that we discussed with the e g al floor section of the previous discussion on E G. D. Outflow obstruction. So I think that this is another nice example of a hernia with an obstruction. Now, this is not an obstruction that's occurring at the Kroll diaphragm per se. This is occurring at the center, and this is likely due to old peptic injury, um, that you will see quite often another example where you may see this is a patient with the subtle presentation of ESPN Filic Esophagitis. Whenever you see early pressurization like this is typically means that there is either an obstruction at the E. J or the wall embody of the Sava Geo. Proper body is non compliant, and that could be either from hypertrophy of the wall or stiffening of the wall related to your center for like, a savage idea. So this someone with a stricture at the L A s not a needy outflow obstruction that is related to a compartmentalized small hernia. And this is something that we don't see that often because most of these places get picked up on endoscopy, but certainly something that does happen occasionally. And we do pick up peptic strictures on Manama tree that are often this bio burned Askey, especially when the referrals. So I think we were able to get through three cases. And like I said, I think this was our first endeavor using the new system and looking at a few cases. And I think going forward with these sessions, it's gonna be really interesting to see whether or not people could send us their own studies so that we can evaluate them together, you know, would be nice to potentially have three studies that are sent in maybe difficult cases. Um, you know that we can actually help out clinically and also help out in terms of, you know, helping everyone get a better understanding of the complex case that most people who who sign onto these they're pretty good at doing the basic stuff. And I think you know, when you start really looking at the complex cases. Um, that's really where I think it moves you from being kind of a general evaluated to someone who is really more of a master interpreter of Manama tree study. So hopefully way still have a few minutes for questions. If anyone has anything left, yes. One related to what you were just speaking about. There was a discussion that I s d e about possible ankle Asia type four. Is it possible that Ah, high irp with compartmentalized pressurization is a type two Eckel Asia in the making? Yes. So certainly, you know the type for originally when we had this description of subjects, we did have type four, which was e g outflow obstruction. I think, you know, I have a new diagram that I actually show. In fact, you know, I can probably bring it up here because I think I have um Yeah, let's see here just really quickly. I can show you H c new subtypes. Here we go. And so this below here is flip. But for the intents and purposes of here, um, I'm gonna just do this. Everyone concerned we move these flip images out of here. This is the slide, so this is actually the progression that typically happen. Certainly, patients started E g j outflow obstruction with intact, peristyle says, and that's early evolving. Um, Ankle Asia. These patients tend to have a normal caliber esophagus. They tend to also have very minimal retention on, um in Asafa Graham and what we've seen. And we have pride in How about six cases where we've had patients present from this evolving UTJ outflow obstruction to type two OCA live Asia? And what you're seeing here, which is very interesting, is that even despite the fact that you don't see the prosthesis, there's probably still some contract. How activity? There may be beautiful prosthesis in here that is just being masked or obliterated by the fact that the massage your body is filled with liquid and there's no contact with the man, a metric catheter. So certainly there is this evolution and in the, you know, in the past, um, you know, if I had this all over again to Dio, I would call e g J outflow obstruction stage one type to stage two and type one stage three Eckel Asia, because that's really the progression that you typically see, but hindsight's 2020. And unfortunately, you know, I've already started with this type 12 and three algorithm that people seem toe toe not want to give up. So So good question. I think the type for really is e g outflow obstruction after you conscientiously ruled out needed the outflow obstruction related to mechanical disorder. Okay, Thank you. At the beginning of your presentation, you mentioned doing a postprandial study for rumination and super gastric belching. Can you give us your protocol for doing that? Yeah. So what we typically do is, and in fact, um, What I find very helpful is, if you're gonna if you're going to see patients for refractory regurgitation or refractory read flux and they're gonna come in for a 24 hour PH. Impedance, I think having high resolution analogy, impedance tow place the less you know, Thio localize. The replacement of the catheter is great, but you need to take that opportunity to get is much information as you can. So what we typically do is the patient comes in. Um, they typically get their high resolution Manama tree with impedance catheter place. We give our standard protocol 10 swallows we local ideally s. And then as soon as they're done with their complete protocol, which also includes biscuits, swallows, multiple rapid swallows and 200 cc um, a large volume swallowing the standing position to mimic a time burying Asafa Graham. Uh, what we typically do is ask the patient to bring in a meal. We have them eat the meal, and then we just watched them for 30 minutes. And with that, we're able to pick up illumination syndrome, super gasic, Belgian patterns, and even, really look to see whether or not they have the typical TSR associate with reef lots. And I'll tell you that we pick up abnormalities that air missed on 24 hour ph impedance. In addition, it also helps us better interpret the findings on 24 hour Ph. Impedance because sometimes you will see beautiful reflux and a picture of refractory reflux on a 24 hour Ph impedance. But what it's related to is either rumination pattern or super Gasic belch induced reflux. So once again, that's how we do it. I think you get a lot of really nice information. The patient is already undergoing a study. It adds about 30 to 45 minutes to the overall study. But I think the amount of information that you get there is extremely important in this very complicated patient population. And certainly you really want to rule out these disorders before you contemplate an escalation of anti reflux therapy. Thank you. Another question. The coral diaphragm moves up as well, along with the L E s in the Swallows that you showed us in your last case study. Does this mean adhesions causing the diaphragm? Um, that is stuck to the lower soft jail sphincter. So No. So what that probably is is that's actually a catheter movement. So if you think about it, um, you know when when you swallow the curl diaphragm shouldn't move all that much. Um, you know, there it should it should, um, you know, track not very well with the center. In fact, that's, you know, the curl diaphragm use is pretty thick. So what happens is it. Sometimes you'll see a straightening of the catheter, and when that straightening is actually improved because the parasol tick waves squeezes the catheter down, you'll see a plunge into the abdomen, and then it looks as if the curl diagram is also moving. So sometimes you see that And that's really mostly related. Thio moving now there is some dynamic property to the title canal. It does move up and down during inspiration, and certainly there is some lacks of there, but it doesn't move. Um, to the level of the lower stop, it'll sink ter, which can move anywhere from two thio eight centimeters up into chest. Okay, Thank you. Another question is is there any news on Endo flip in the US concerning LPR? No, not really. At this point, I think there are some people looking at it. It's a hard device, though, to use in the upper sink there because of the balloon nature of it, and you know it SSM what? Difficult. But there are people studying, and there are a couple of papers that are either accepted and gonna be impressed soon. But certainly that might be something I think they just need to change if I need to make a more narrow balloon and it's short of them. Okay, I believe that takes us to our one o'clock time. All right. Well, great. Well, this was a nice experience and a nice, uh, first time effort on using the new software. And I think we'll get better and better in this. And I think we'll get better cases too. So thanks, everybody. Have a good day. Thank you, Doctor. Panicked Hanafin, on behalf of Sand Hill. Thank you very much for your time. Today was an excellent presentation and some of the questions that we didn't get a chance to answer. Outstanding. We'll try to get back to everyone with responses, Thank you all very much and have a wonderful holiday next week. All have a good day. Take it easy. 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
