Esophageal and Gastric Conflicts of Interest: Motility Disorders: A case • None based approach Gokul Balasubramanian, MD Assistant Professor Director of Gastrointestinal Motility Lab Division of Gastroenterology, Hepatology and Nutrition The Ohio State University Wexner Medical Center Overview • Esophageal anatomy • Dysphagia-case based approach • Reflux disease-case based approach Dysphagia-Case • Gastric physiology based approach • Gastroparesis-case based approach 1 Esophagus: Anatomy Terminology • 25 cm muscular tube. • Dysphagia: derived from the Greek word dys (difficulty, disordered) and phagia (to eat). • Extends from upper esophageal sphincter to stomach. • Odynophagia: painful swallowing. • Proximal 1/3rd consist of striated muscles while distal • Globus Sensation: Sensation of lump in throat 2/3rd is formed by smooth muscles. between meals. • Lined squamous epithelium. History Dysphagia Assessment Oropharyngeal Esophageal Fluoroscopic • Oral: • Food stuck in examination ‒ Drooling of saliva suprasternal notch or ‒ Food spillage retrosternal region ‒ Sialorrhea ‒ Piecemeal swallows • Motility: ‒ Associated dysarthria ‒ dysphagia to solids and liquids • Pharyngeal: ‒ Associated with ‒ Choking/cough during heartburn or chest pain. swallow • Mechanical: ‒ Associated dysphonia Endoscopic Manometric ‒ progressive dysphagia to examination examination solids; may involve liquids at later stages 2 Case Study 1: Case Study 1: 78-year-old female with no significant medical history presenting with: ‒ Dysphagia to both solids and liquids ‒ Chest pain ‒ Denies any heartburn • Mean DCI:2380 ‒ 50 lb weight loss • Mean LES IRP:32 mm Hg • Mean DL: 3.8 sec • Epiphrenic diverticulum • Epiphrenic diverticulum • Resistance at GEJ • Beaking at GEJ Case Study 1: Achalasia • Post extended myotomy and diverticulectomy • Rare esophageal motility • Fairly doing disorder • Esophageal aperistalsis • Impaired LES relaxation Loss of inhibitory neurons secreting VIP and NO leads to unopposed excitatory activity and failure of LES relaxation DA Patel. An Overview of Achalasia and Its Subtypes. Gastroenterology & Hepatology. Volume 13, Issue 7 July 2017 3 Achalasia: Subtypes Achalasia: Treatment Algorithm Type I is characterized by a quiescent esophageal body, type II has pan-esophageal pressurization, and type III is characterized by simultaneous contractions. DA Patel. An Overview of Achalasia and Its Subtypes. DA Patel. An Overview of Achalasia and Its Subtypes. Gastroenterology & Hepatology. Volume 13, Issue 7 July 2017 Gastroenterology & Hepatology. Volume 13, Issue 7 July 2017 Achalasia: Treatment Options Case Study 2: Treatment Options Pros Cons • On Demand Medications(CaCB/Nitrate • Minimal risk • Least effective 24-year-old s) • For non-operative • Not durable female presented candidates • Good option for with dysphagia to nonoperative • Durability of 6–12 solids and Botulinum toxin injection candidates months liquids. • Short procedure time • Most effective • Mean DCI:NA nonsurgical option • Mean LES IRP:24 mm Hg • Short recovery time • Perforation (1%– Pneumatic dilation • Mean DL: NA • Durability 2–5 years 5%) • Procedure time <30 Diagnosis?? minutes • General anesthesia • Durability 5–7 years required Surgical myotomy • Procedure time 90 ∼ • Hospital stay of 1–2 minutes days Type 2 Achalasia. Patient • High morbidity and Esophagectomy • For end-stage disease mortality sent for myotomy 4 Case Study 3: Opioid-induced esophageal dysfunction 64-year-old female with CAD, chronic backache on morphine is presenting dysphagia Opioid-induced esophageal and spasmodic pain in dysfunction is often characterized the neck and chest. by EGJ outflow obstruction and type III achalasia pattern. • Mean DCI:2765 • Mean LES IRP:18 mm Hg • Mean DL: 3.8s Diagnosis?? Opioid induced esophageal dysfunction Ratuapli S, et al.Opioid-Induced Esophageal Dysfunction (OIED) in Patients on Chronic Opioids. Am J Gastroenterol 2015; 110:979–984; Achalasia syndromes beyond the CC v3.0 GERD-Case based approach Kahrilas, P. J. et al. (2017) Advances in the management of oesophageal motility disorders. in the era of high-resolution manometry: a focus on achalasia syndromes. Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2017.132 5 Gastroesophageal Reflux Risk factors: Disease Definition • Obesity GERD is a condition that develops • Family history for GERD when the reflux of gastric content • Tobacco smoking causes troublesome symptoms or • Alcohol consumption complications. • Associated psychosomatic complaints • Mild symptoms once in > 2 days/week • Moderate/Severe once in >1 day/week Vakil N, van Zanten SV, Kahrilas P, et al. Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Locke GR, et al. The American Journal of Medicine. 1999;106(6):642-649 Gastroenterol. 2006;101:1900–1920. Hampel H. Ann Intern Med. 2005;143(3):199-211. Impact of Gastroesophageal Reflux Disease Gastroesophageal Reflux Disease Esophagitis Extra-esophageal Non-erosive GERD GERD (EGD negative) Stricture Bleeding ENT Impairs quality Barrett’s metaplasia Asthma of life & Adenocarcinoma Dental Irvine EJ, Hunt RH. Evidence-Based Gastroenterol. BC Decker Inc. Hamilton and London. 2001. 6 Goals for Treatment of GERD Life-Style Modifications include: • Eliminate symptoms • Elevate the head of the bed on 4" to 6" blocks. • Advise weight loss for obese patients. • Heal erosive esophagitis • Avoid recumbency for 3 hours after meals. • Avoid bedtime snacks. • Prevent the relapse of erosive • Avoid fatty foods, chocolate, peppermint, onions, and esophagitis and complications from garlic. GERD • Avoid cigarettes and alcohol. • Avoid drugs that decrease LES pressure and delay gastric emptying. Medical treatment options: Maintenance of Healing Erosive Esophagitis Proton Pump Inhibitors: • Higher healing rates in mild to moderately severe reflux esophagitis(80% to 100%). 100 Esomeprazole 40 mg 80 20 mg • Improves dysphagia. 10 mg 60 Placebo • Decreases the need for esophageal dilation in patients 40 who have peptic esophageal strictures. Remission In (%) 20 • About 70% may have nocturnal acid breakthrough that 0 0123 4 5 6 requires H2RA. Months Pooled from Johnson DA, et al., Am J Gastroenterol, 2001;96:27-34 and Vakil NB, et al., Aliment Pharmacol Ther, 2001;15:927-935. 7 GERD Is a Chronic Condition Appropriateness of PPI use Likely to Relapse 100 No mucosal breaks LA Grade A 80 LA Grade B 60 LA Grade C (%) 40 20 Patients in Symptomatic Remission 0 0123456 Time After Cessation of Therapy (Months) Lundell LR, et al. Gut. 1999;45:172-180. Yadlapati and Kahrilas BMC Medicine (2017) 15:36 Medical treatment options: • Antacids and Alginic Acid: ‒ Temporarily relieve episodic heartburn ‒ Useful add on therapy • Histamine H2-Receptor Blocking Agents: ‒ Safe and effective in mild esophagitis Decisions to start, properly dose, ‒ Not useful in severe esophagitis continue, or discontinue PPI ‒ Useful for breakthrough symptoms therapy should be personalized ‒ Concern for tachyphylaxis based on indication, effectiveness, • Prokinetic Agents: patient preferences, and risk ‒ Limited efficacy and side effects in up to 30% assessment. • TLESR Inhibitors: ‒ As addon for non-acid reflux/post prandial reflux Yadlapati and Kahrilas BMC Medicine (2017) 15:36 8 Indications for anti-reflux surgery Case Study 4: • Unwillingness to remain on medical therapy • Intolerance of medical therapy 42-year-old female with • Medically refractory symptoms with objective prior history of evidence of GERD scleroderma is presenting • GERD in the setting of a large hiatal hernia with persistent reflux inspite of twice daily PPI, referred for fundoplication. • Mean DCI:NA • Mean LES IRP:2mm Hg • Mean DL: NA Badillo R, Francis D. Diagnosis and treatment of gastroesophageal reflux disease. World J Gastrointest Pharmacol Ther. 2014;5(3):105-12. Case Study 4: Case Study 4: • Acid exposure: • Total AET:14.5% • Reflux events:112 • Educated on lifestyle measures. • Reflux symptom analysis: • SI:54 • Added H2B at bedtime. • SAP: 98 • Was doing much better. What would be the next step? 9 Case Study 5: Case Study 5: • 28 yr old female • Acid exposure: with anxiety • Total AET:10.5% presenting with • Reflux events:119 • Reflux symptom analysis: persistent • SI:50 heartburn inspite • SAP: 96 of PPI twice daily • EGD: normal What would be the esophagus with next step? biopsy DDx to PPI-Refractory GERD Effect of DBT on belching and GERD • Refractory reflux • Refractory reflux symptoms with symptoms with normal esophagitis esophagus • Eosinophilic esophagitis • Eosinophilic esophagitis • Pill induced esophagitis • Achalasia • Skin disorders like • Gastroparesis Lichen planus • Aerophagia and • Hypersecretory Belching disorder condition like ZES • Rumination syndrome • Genotypic differences in • Functional heartburn CYP450 2C19 Ong et al.Diaphragmatic Breathing Reduces Belching and Proton Pump Inhibitor Refractory Gastroesophageal Reflux Symptoms. Clinical Gastroenterology and Hepatology 2018;16:407–416 10 Case Study 5: • Continued PPI, • Started on behavioral therapy and Gastroparesis-Case anti-anxiety medication, • Educated on DBT based approach Physiology of stomach Normal Velocities of emptying of solid and liquid chyme. 11 Definition: Etiology of Gastroparesis Gastroparesis Gastroparesis is defined as a delay in the emptying of ingested food in Idiopathic Diabetic Post-surgical the absence of mechanical gastroparesis gastroparesis gastroparesis (30-35%) Cholecystectomy