NOME E NUMERO DEL PROVIDER: I&C SRL - 7598ECM N°: 11005555
TITOLO: XIV CONGRESSO NAZIONALE GISMAD
SEDE: VENEZIA-MESTRE
DATA: 18-19 MARZO 2011
Il sottoscritto EDOARDO SAVARINO
in qualità di docente dell’evento sopra indicato,
ai sensi dell’art. 3.3 sul Conflitto di Interessi, pag. 17
del Reg. Applicativo dell’Accordo Stato-Regioni del 5/11/09, per conto del
provider I&C srl
dichiara
che negli ultimi due anni
non ha avuto rapporti con soggetti portatori
di interessi commerciali in campo sanitario
Impatto delle Tecnologie
sulla gestione clinica:
pH e Manometry-Impedance
Dott. Edoardo V. Savarino
Dipartimento di Medicina Interna,
Clinica di Gastroenterologia con
Endoscopia Digestiva, Università di
Genova (Resp. Prof. V. Savarino)
Combined impedance-manometry
20cm
20cm
15cm
15cm
10cm
10cm
5cm
5cm
LES
NEW
TECHNOLOGIES
17 cm
15 cm
6 impedance channels
Esophageal pH monitoring
without catheter
9 cm
1 pH channel
7 cm
5 cm
3 cm
pH - 5 cm
Impedance Monitoring
Kahrilas PJ.
Impedance Monitoring: When?
►
Evaluation of patients with difficult symptoms
Non-Cardiac Chest Pain – Disphagia – Globus
►
Evaluation of symptomatic patients despite PPI therapy
Efficacy of Medical Therapy – Correlate Acid &
Non-Acid GER to Sx – Absence of abnormal GER
►
Evaluation of atypical GERD (Correlate acid & nonacid GER episodes to
Sx and quantify proximal extent of GER)
Cough – Asthma – Laryngitis – Hoarseness –
Bronchitis - Dysfonia – Interstitial Lung Disease
►
Pre and Post-operative evaluation of patients considered for surgery
Pathological acid exposure – Symptom-reflux
Association – Efficacy of surgery
►
Evaluation of GERD in infants and pediatric patients
Pathological non-acid exposure – Nocturnal apnea
►
Evaluation of new medical or endoscopic therapies for GERD
(Baclofen, Esophyx, Arbaclofen, Lesogaberan etc.)
Main Diagnostic Advantage
Does patient have a reflux disease?
MII-pH Impedance Monitoring
In case of normal acid exposure
Positive Symptom Association
Negative Symptom Association
Identify Non-Acid Reflux
Disease
Identify Functional Diseases
or search for other causes
Clinical Utility of Impedance-pH in NERD patients
NERD Patients
(N = 150)
Normal Acid Exposure Time
87 (58%)
Abnormal Acid Exposure Time
63 (42%)
Positive SI
54 (36%)
Negative SI
9 (6%)
Acid Only
48 (32%)
Acid and Nonacid
4 (3%)
Total Acid
52 (35%)
Positive SI
45 (30%)
Negative SI
42 (28%)
Nonacid Only
2 (1%)
Functional
Heartburn
42 (28%)
Total Nonacid
6 (4%)
Acid Only
20 (13%)
Acid and Nonacid
7 (5%)
Total Acid
27 (18%)
Nonacid Only
18 (12%)
Total Nonacid
25 (17%)
Savarino E et al. Am J Gastroenterology 2008;103:1-9
The Added Value of Impedance-pH to Rome III
Criteria in NERD patients (N=219)
50%
45%
% of patients
40%
38%
39%
35%
31%
30%
25%
20%
28%
29%
28%
3%
10%
NARD
15%
10%
5%
5%
2%
0%
NERD pH+/SAP+
NERD pH+/SAPRome III Criteria
HE
FH
MII-pH/SAP Results
Savarino E et al. Dig Liv Dis 2011; March 2
Rome Criteria 3 ½
Kahrilas PJ et al. Am J Gastroenterology 2010;747:756
Clinical Utility of Impedance-pH in EE patients
EE Patients
(N = 58)
Normal Acid Exposure Time
11 (19%)
Abnormal Acid Exposure Time
47 (81%)
Positive SAP
44 (76%)
Negative SAP
3 (5%)
Acid Only
35 (60%)
Acid and Nonacid
5 (9%)
Total Acid
40 (69%)
Positive SAP
10 (17%)
Negative SAP
1 (2%)
Nonacid Only
4 (7%)
Total Nonacid
9 (16%)
Acid Only
3 (5%)
Acid and Nonacid
3 (5%)
Total Acid
6 (10%)
Nonacid Only
4 (7%)
Total Nonacid
7 (12%)
Savarino E et al. Am J Gastroenterology 2010; 105:1053-61
Clinical Utility of Impedance-pH in EE patients
Frazzoni M et al. APT 2011; 33:601-606
Impedance-pH and overlap syndromes
Savarino E et al. Gut 2009; 58:1185-1191
Impedance-pH and overlap syndromes
NERDNERD
pH-POS/SAP-
NERD pH-POS/SAP+
NERD
70
NERD pH-NEG/SAP
+
HE
NERD pH-NEG/SAP
FH
*
61
*
60
% of patients
*
54
* = p <0.01
50
50
50
*
41
40
40
35
34
29
30
30
28
26
40
28
34
30
23
20
20
22
20
18
15
20
18
14
10
10
20
10
11
10
7
8
0
Postprandial Early Satiety
Fullness
Bloating
Nausea
Belching
Epigastric
Pain
Epigastric
Burning
Vomiting
Savarino E et al. Gut 2009; 58:1185-1191
Impedance-pH and new drugs
*p<0.05
*
*
*
*
Impedance-pH and new drugs
Impedance-pH and surgery
Impedance-pH and surgery
Patients selection:
 15 had erosive esophagitis
 16 had non-erosive reflux disease
Laparoscopic Nissen Fundoplication
↓ Number of total, acid and weakly acidic reflux episodes
↓ Acid exposure time, liquid and mixed reflux events
↓ Gatric belching, but ↑ Supragastric belching
16 Patients were asymptomatic
15 Patients were symptomatic, but with negative SI for acid or weakly acidic reflux
Impedance-pH and surgery
No symptom was registered during the
study performed after intervention
38 were totally asymptomatic
Subtotal symptom remission was
reported by two patients, one with a
postoperative heartburn score of 1
(3 before intervention) and one with a
post-operative regurgitation score of 1
(3 before intervention)
Impedance-pH: On or Off-PPI Therapy?
Twice-daily PPI
Therapy for at least
2 months
Impedance-pH
Testing On
Therapy
Impedance-pH: On or Off-PPI Therapy?
N=30
Hemmink et al. Am J Gastroenterology 2008; 103:2446-53
Impedance-pH: On or Off-PPI Therapy?
Impedance
Impedance-pH as the gold
standard to test if the
patient has or not GERD in
the first place
Impedance-pH as the gold
standard to clarify the
relationship between
symptoms and reflux
Off Therapy
On Therapy
History of Erosive esophagitis or Barrett Esophagus
Previous positive conventional pH monitoring
Modified by Tutuian R. J Gastrointestin Liver Dis 2009; 1:9-10
Definition of Motility Abnormalities
Esophageal body
LES resting pressure
LES residual pressure
100% aperistalsis
elevated / normal
elevated / normal
IEM
>30% ineffective contractions
normal / low
normal
DES
>20% simultaneous swallows
normal / elevated
normal
< 30% ineffective
< 20% simultaneous
normal
normal
normal; DEA >180mmHg
normal / elevated
normal / elevated
Hypertensive LES
normal
> 45 mmHg
elevated / normal
Poorly relaxing LES
normal
normal
> 8 mmHg
Hypotensive LES
normal
< 10 mmHg
normal
Achalasia
Normal
Nutcracker
IEM – ineffective esophageal motility
DES – distal esophageal spasm
LES – lower esophageal sphincter
Spechler & Castell. Gut 2001; 49:145-51
Meaning
of esophageal motility
abnormalities ?
Esophageal Function Testing
Combined Impedance-Manometry Comprehensively Assesses Esophageal Function
Motility Assessment Criteria
Pressure Measurements
Esophageal Body Contraction Amplitude
Bolus Transit Measurements
LES Resting Pressure
Complete
Esophageal Body Contraction Velocity
LES Residual Pressure
Incomplete
Impedance-Manometry Testing
20cm
20cm
15cm
15cm
10cm
10cm
5cm
5cm
LES
Video-fluoro vs. Impedance
r = 0.94
Simren et al. Gut 2003; 52:784-790
Bolus Transit
Complete bolus transit
20 cm
15 cm
10 cm
5 cm
2 cm
Bolus retention at 15cm
Patients with esophageal
motility abnormalities

350 patients


Females 220 (63%), males 130 (37%)
Age: mean 53.5 years, range 12-86 years
Tutuian R et al. Am J Gastroenterology 2004; 99:1011-9
Percentage of Patients with normal bolus transit for
liquid based on manometric diagnosis (n=350)
Tutuian R et al. Am J Gastroenterology 2004; 99:1011-9
Impedance-manometry classification
of motility abnormalities
Pressure and Transit
Pressure only
Hypertensive LES
Achalasia
Scleroderma
Hypotensive LES
IEM
Poor relaxing LES
DES
Nutcracker
Mild Moderate Severe
Tutuian R et al. Am J Gastroenterology 2004; 99:1011-9
Frequency of bolus retention at different
levels in the esophagus (n=67 patients)
(Bread)
Chest-pain
Dysphagia
40% 30% 20% 10% 0% 10% 20% 30%40% 40% 30% 20% 10%
p<0.05 at each level
GERD
0% 10% 20% 30% 40% 40% 30% 20% 10% 0% 10% 20% 30% 40%
20
15
10
5
2
% swallows with bolus retention
DDW 2007, Washington, USA
Manometric Findings in 755 GERD Patients and 48 HVs
FISMAD 2011, Torino, Italy
AUMENTO
N=48
N=70
N=239
Simile prevalenza di IEM tra HV e
FH
N=340
N=106
DELL’INCIDENZA DI IEM
CON L’AUMENTARE
DELLA SEVERITA’ DELLE
LESIONI
Bolus Transit for Liquid Swallows in GERD Patients
Valori simili tra FH e NERD
Bolus
Transit
alterato
in
Pazienti con lesioni visibili
endoscopicamente
FISMAD 2011, Torino, Italy
Manometric Diagnosis with Bolus Transit in
GERD Patients
Conventional Manometry
Combined Impedance Manometry
90%
80%
Patients (%)
70%
22%
60%
21%
50%
40%
0%
30%
20%
36%
4%
52%
56%
EE (N=65)
BARRETT (N=34)
31%
10%
0%
FH (N=39)
NERD (N=122)
FISMAD 2011, Torino, Italy
Future Issues to be Elucidated
 The impact of Bolus Transit assessment in patients
undergoing esophageal surgery (Fundoplication, Heller
Miotomy, Trans-oral esophageal diverticulectomy etc.)
 The diagnostic utility of Bolus Transit assessment in patients
with non-obstructive dysphagia (functional dysphagia etc.)
 The impact of Bolus Transit assessment in studies aimed at
testing future drugs for improving gastro-esophageal emptying
(Bolus transit time)