Esophageal impedance monitoring. Daniel Sifrim MD, PhD

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1 Esophageal impedance monitoring Daniel Sifrim MD, PhD

2 εμπέδηζη IMPEDANCE, the measurement

3 εμπέδηζη Swallow

4 εμπέδηζη Swallow Reflux

5 IMPEDANCE, the techniques εμπέδηζη Ambulatory ph-impedance

εμπέδηζη Stationary manometry-impedance 12:14:58 1 A 0.00 S 8.02 water water 2 A 6.73 S 8.10 3 A -7.40 S 8.

6 εμπέδηζη Stationary manometry-impedance 12:14:58 1 A 0.00 S 8.02 water water 2 A 6.73 S A S A S A S A S A S A S A S

7 εμπέδηζη Stationary manometry-impedance

8 IMPEDANCE, the interpretation Patterns of gastroesophageal reflux Impedance 1 sw sw sw sw 3 k Impedance 2 3 k Impedance 3 3 k Impedance 4 3 k ph esophagus s 10s 10s acid reflux Weakly acidic reflux Weakly alkaline reflux Sifrim et al 2004

9 εμπέδηζη Non-acid and weakly acidic reflux H O 2 H + + OH [H ] (mmol/l) ph (-log(mol/l)) acid alkaline Chemist acid Weakly acidic neutral Weakly alkaline Oporto 2002 acid non-acid Traditional GI 9 η Tutuian Εκπαιδευηική R διημερίδα ΕΠΕΓΕ, Αθήνα 24 Εκπαιδευηική διημερίδα ΕΠΕΓΕ, Αθήνα Σεπηεμβρίου 2011

10 Patterns of bolus transit Complete transit Incomplete transit εμπέδηζη

11 IMPEDANCE, problems with interpretation ph only = relevant reflux? εμπέδηζη Impedance-pH ph reflux

12 εμπέδηζη

13 εμπέδηζη

14 εμπέδηζη

15 εμπέδηζη

16 IMPEDANCE, the clinical application εμπέδηζη Gastroesophageal reflux (24hs ambulatory ph-impedance) Non-obstructive obstructive dysphagia (1/2h stationary manometry-impedance with liquids and semi solids) Aerophagia and belching (2hs ambulatory impedance with high frequency sampling: 1000Hz) Rumination syndrome vs. postprandial belching (2hs postprandial stationary manometry-impedance)

17 εμπέδηζη Analysis clinical research

18 Analysis of ambulatory ph-impedance monitoring εμπέδηζη Clinical setup 1) Visual evaluation of the tracing (technical problems) 2) Adding or correction of symptom events 3) Running automatic analysis (fast editing of false positives) 4) Report Number of reflux Number of symptoms Exposures» Acid (total and impedance reflux related)» Volume 5) Visual evaluation of symptom association followed by editing of automatic SI and SAP

19 Analysis of ambulatory ph-impedance monitoring εμπέδηζη Research setup 1) Full visual evaluation of the tracing 2) Adding or correction of symptom events 3) Report Number of reflux Number of symptoms Exposures» Acid (total and impedance reflux related)» Volume 5) Visual evaluation of symptom association

20 εμπέδηζη

21 εμπέδηζη

22 ph-impedance in patients with GERD on PPI εμπέδηζη

23 εμπέδηζη ph-impedance in patients with chronic cough Blondeau et al 2007

24 εμπέδηζη ph-impedance in patients with chronic cough Blondeau et al 2007

25 εμπέδηζη Non-obstructive dysphagia (1/2h stationary manometry-impedance with liquids and semi solids)

26 εμπέδηζη Relationship between abnormal manometry and bolus clearance normal manometry abnormal manometry abnormal manometry normal bolus transit abnormal bolus transit normal bolus transit Tutuian et al 2004

27 Bolus transit in esophageal motor disorders εμπέδηζη 100% 95% 97% 100% 96% 100% 80% 60% 40% 51% 55% 20% 0% 0% 0% achalasia scleroderma IEM DES normal nutcracker poor relaxing LES hypertensive LES hypotensive LES Tutuian et al 2004

28 Distal Esophageal Spasm Achalasia εμπέδηζη Tutuian and Castell 2006 Conchillo et al DDW 2006

29 εμπέδηζη Bolus transit and perception of dysphagia 10:59:47 1 A S controls manometry N bolus transit N Dysphagia score fluid passage slow passage stepwise passage partial blockade complete blockade A S A S A S A S A S A S A S perception N Karamanolis et al 2006

30 εμπέδηζη Bolus transit and perception of dysphagia controls GERD manometry N bolus transit N manometry Ab bolus transit Ab 10:59:47 1 A S Dysphagia score fluid passage slow passage stepwise passage partial blockade complete blockade A S A S A S A S A S A S A S perception N HYPOSENSITIVE? Karamanolis et al DDW 2006

31 εμπέδηζη Bolus transit and perception of dysphagia controls GERD manometry N bolus transit N manometry Ab bolus transit Ab manometry N bolus transit N 10:59:47 1 A S Dysphagia score fluid passage slow passage stepwise passage partial blockade complete blockade A S A S A S A S A S A S A S perception N HYPOSENSITIVE? HYPERSENSITIVE?

32 εμπέδηζη abnormal manometry abnormal bolus clearance normal bolus clearance mechanical or real dysphagia disordered perception Conchillo,et al 2005

33 εμπέδηζη Aerophagia and belching

34 εμπέδηζη Bredenoord et al 2006

35 εμπέδηζη Aerophagia and belching 14:43:01 1 A Event Event Event Event Event Event Event S A S A S A S A S A S A S A S

36 εμπέδηζη Aerophagia and belching 14:42:39 1 A S Event 2 A S A S A S A S A S A S A S

37 εμπέδηζη Aerophagia and belching Patients with GERD swallow air more frequently and belch more frequently than healthy subjects Bredenoord et al 2006

38 Rumination syndrome εμπέδηζη

39 Rumination syndrome εμπέδηζη Aprile, Dantas, Oliveira, Sifrim 2008

40 Rumination syndrome εμπέδηζη 12:24:04 1 A S A S A S A S A S A S A S A S A S

41 Rumination syndrome vs belching εμπέδηζη 12:03:34 1 A S A S A S A S A S A S A S A S A S

42 εμπέδηζη Gastroesophageal reflux (24hs ambulatory ph-impedance) Non-obstructive dysphagia (1/2h stationary manometry-impedance with liquids and semi solids) Aerophagia and belching (2hs ambulatory impedance with high frequency sampling: 1000Hz) Rumination syndrome vs. postprandial belching (2hs postprandial stationary manometry-impedance)

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