6/15/2020 Joint ACG/ANMS Webinar Restarting Your Motility Practice Participating in the Webinar All attendees will be muted and will remain in Listen Only Mode. Type your questions here so that the moderator can see them. Not all questions will be answered but we will get to as many as possible. 1 Joint ACG/ANMS Webinar Restarting Your Motility Practice How to Receive CME and MOC Points LIVE VIRTUAL GRAND ROUNDS WEBINAR ACG will send a link to a CME & MOC evaluation to all attendees on the live webinar. ABIM Board Certified physicians need to complete their MOC activities by December 31, 2020 in order for the MOC points to count toward any MOC requirements that are due by the end of the year. No MOC credit may be awarded after March 1, 2021 for this activity. ACG will submit MOC points on the first of each month. Please allow 3-5 business days for your MOC credit to appear on your ABIM account. 2 Joint ACG/ANMS Webinar Restarting Your Motility Practice MOC QUESTION If you plan to claim MOC Points for this activity, you will be asked to: Please list specific changes you will make in your practice as a result of the information you received from this activity. Include specific strategies or changes that you plan to implement. THESE ANSWERS WILL BE REVIEWED. 3 American College of Gastroenterology 1 6/15/2020 Joint ACG/ANMS Webinar Restarting Your Motility Practice ACG Virtual Grand Rounds Join us for upcoming Virtual Grand Rounds! Week 13: Health Maintenance for the Patient with IBD Francis A. Farraye, MD, MSc, FACG June 18, 2020 at Noon EDT Week 14: EOE and EGID: Pearls and Pitfalls Kathy A. Peterson, MD, Msci June 25, 2020 at Noon EDT Visit gi.org/ACGVGR to Register 4 Joint ACG/ANMS Webinar Restarting Your Motility Practice Disclosures: Dr. Pochapin Dr. Baker Dr. Gyawali Dr. Moshiree Dr. Chey Dr. Rao Dr. Khan Dr. Pandolfino According to ACCME guidance, because there are no current preventive or specific treatments for coronavirus infection, there are no relevant conflicts of interest for any speakers or moderators. 5 Joint ACG/ANMS Webinar Restarting Your Motility Practice 6 American College of Gastroenterology 2 6/15/2020 Joint ACG/ANMS Webinar Restarting Your Motility Practice Jason R. Baker, PhD Atrium Health University of North Carolina Charlotte 7 Joint ACG/ANMS Webinar Restarting Your Motility Practice • Personal Protective Equipment (PPE) and Motility/GI Physiology Laboratory related to COVID‐19 Pandemic • Motility/GI Physiology Laboratory workflow to protect Allied Health Professionals and Patients from spreading COVID‐19 • Suggested additional Motility/GI Physiology Laboratory suite air‐ filtration techniques related to COVID‐19 8 Joint ACG/ANMS Webinar Restarting Your Motility Practice • Primary reason to for Allied Health Professionals/Motility Providers to utilize appropriate PPE for GI Physiology/Motility Testing • GI Physiology/Motility Testing is a Partnership Relationship • Allied Health Professionals and Patient 9 American College of Gastroenterology 3 6/15/2020 Joint ACG/ANMS Webinar Restarting Your Motility Practice Motility Laboratory Procedure PPE Recommendations Esophageal Physiologic Procedures N95 mask, double gloves, face shield (and/or alternate protective eye wear), and gown Antroduodenal Manometry N95 mask, double gloves, face shield, (and/or alternate protective eye wear), and gown Colon Manometry N95 mask, double gloves, face shield (and/or alternate protective eye wear), and gown Wireless Motility Capsule N95 mask, or surgical mask with a face shield, gloves, face shield (and/or alternate protective eye wear), and gown Gastric Emptying Breath Test N95 mask, gloves, face shield (and/or alternate protective eye wear), and gown Anorectal Function Testing N95 mask or surgical mask with face shield (and/or alternate protective eye wear), double gloves, and gown Hydrogen Breath Testing N95 mask, gloves, face shield (and/or alternate protective eye wear), and gown 10 Joint ACG/ANMS Webinar Restarting Your Motility Practice Motility/GI Physiology Laboratory Test Scheduled 48 Hours Prior to Date of Motility/GI Physiology Laboratory Test a COVID‐ 19 Test is Required Verify COVID‐19 Test Results: Document COVID‐19 Results Perform Motility/GI Physiology Laboratory Test Using Recommended PPE Thoroughly Clean Motility/GI Physiology Laboratory Suite Between Each Patient Reprocess Catheters Using Manufacturer Recommended Instruction for Use (IFU) 11 Joint ACG/ANMS Webinar Restarting Your Motility Practice • High‐Efficiency Particulate Air (HEPA) Filters: • Device used to prevent airborne infections • Filters up to 99.7% of airborne particles of 0.3 μm in diameter • Time and Speed • Adjusted by the number of exchanges and square foot of the Motility/GI Physiology Laboratory suite • If HEPA is unavailable: • Follow institutional control measures 12 American College of Gastroenterology 4 6/15/2020 Joint ACG/ANMS Webinar Restarting Your Motility Practice • Personal Protection Equipment (PPE) measures will provide safety for both the Motility/GI Physiology Allied Health Professional and Patient in relation to COVID‐19 • Implementing a COVID‐19 Motility/GI Physiology Laboratory strategic workflow enhances safety and effective communication • Utilizing additional air‐filtration system may be an adjunct to standard institutional quality control measures related to COVID‐19 cleaning standards 13 Joint ACG/ANMS Webinar Restarting Your Motility Practice C. Prakash Gyawali, MD Washington University in St. Louis 14 Joint ACG/ANMS Webinar Restarting Your Motility Practice Most esophageal physiologic testing is elective esophageal manometry has alternatives: barium esophagography, endoscopy, FLIP medical reflux management can proceed without ambulatory reflux monitoring emergent anti-reflux surgery can be performed without physiologic testing neuromodulators and complementary approaches used when reflux symptoms persist Emergent reflux monitoring is hardly ever needed wireless pH monitoring can be performed during endoscopy Esophageal manometry confirms achalasia diagnosis prior to LES disruption symptoms can be temporized by adjusting diet and eating habits botulinum toxin injection during diagnostic endoscopy can provide short term relief a timed upright barium study can demonstrate esophageal outflow obstruction in achalasia FLIP during endoscopy can diagnose achalasia; hydraulic FLIP dilation can treat achalasia Lee YY et al. CGH 2020 15 American College of Gastroenterology 5 6/15/2020 Joint ACG/ANMS Webinar Restarting Your Motility Practice Accepted indications Transit symptoms not explained by endoscopy and/or barium studies Suspicion of major motor disorders (especially achalasia) Assessment of esophageal peristaltic performance Assessment of unexplained esophageal symptoms Diagnosis of rumination syndrome and supragastric belching Evaluation of post fundoplication dysphagia Diagnosis of functional esophageal disorders (by exclusion of major motor disorders) Localization of the LES for appropriate placement of pH and pH-impedance catheters Emerging indications Assessment of morphology and integrity of the esophagogastric junction Measurement of hiatus hernia size Assessment of esophageal peristaltic performance prior to bariatric procedures Savarino E, Roman S, Gyawali CP, et al., Nature Reviews Gastroenterol Hepatol 2017 14:665-676 16 Joint ACG/ANMS Webinar Restarting Your Motility Practice Any form of reflux monitoring off PPI high pre-test probability of reflux, confirmation prior to invasive or long-term GERD therapy any situation with unproven GERD and typical reflux symptoms pH-impedance monitoring off PPI (with limited exceptions) persisting reflux symptoms despite PPI in proven GERD (testing performed on PPI) suspicion of reflux-related micro-aspiration, especially pre-lung transplant repetitive belching syndromes suspicion of rumination syndrome persistent symptoms following invasive antireflux procedures Wireless pH monitoring off PPI intolerance of the transnasal catheter infrequent symptoms, where reflux-symptom association is needed high clinical suspicion of GERD but negative 24-hour reflux monitoring very low clinical suspicion of GERD, to rule out GERD Sifrim D, Gyawali CP. Am J Gastroenterol 2020 17 Joint ACG/ANMS Webinar Restarting Your Motility Practice Clinical Qualifiers Alternative approach if procedure is not available HRM in suspected achalasia Significant dysphagia with inability to EGD with endotracheal intubation and with severe symptoms maintain hydration and nutrition. FLIP for diagnosis. Barium esophagography for diagnosis. EGD with endotracheal intubation and Dobhoff tube or gastrostomy tube placement if treatment is delayed. HRM prior to achalasia Plans for urgent management (PD or EGD with endotracheal intubation and management myotomy) FLIP followed by pneumatic dilation. EGD with endotracheal intubation, FLIP and botulinum toxin injection. Barium esophagography for diagnosis (if no prior confirmation of diagnosis) and myotomy referral. HRM prior to hernia Large hiatus hernia, risk for aspiration or Barium esophagography for diagnosis. surgery volvulus. Inability to maintain hydration *Evidence of ischemia: proceed to and nutrition. emergent surgery Lee YY et al. CGH 2020; ANMS Task Force document 2020, motilitysociety.org 18 American College of Gastroenterology 6 6/15/2020 Joint ACG/ANMS Webinar Restarting Your Motility Practice Clinical Qualifiers Alternative approach if procedure is not available HRM Dysphagia with weight loss Empiric management with PPI, (Transition to an urgent