Achalasia Flashcards
(27 cards)
Difference between HRM and conventional manometry
Number of sensors and spacing between the sensors
Clouse Plot (Oesophageal pressure topography) 1) 2) x axis 3) y axis 4) color
1) 3D plotting format
2) time
3) location within esophagus
4) pressure
HRM Patient protocol
First: supine, catheter positioned, 10-swallows, each with 5 mol of water
Multiple rapid swallow sequence (MRS):five liquid swallows, 2 mL each, 2-3 seconds apart
Third: upright position, five swallows, 5ml water/saline
Rapid drink challenge: ingestion of 200ml of water as quickly as possible
HRM pressure topography landmarks
Anatomic sphincters (UES, LES)
Contractile segments
Transition zone
Contractile deceleration point
EPT metrics
integrated relaxation pressure distal latency distal contractile integral contraction vigor contraction pattern pressurisation pattern
Integrated relaxation pressure
1) Significance
2) Definition
3) Normal value
1) assessing adequacy of OGJ relaxation during swallowing
2) average minimum EGJ pressure for 4 sec of relaxation within 10 seconds of swallowing
3) ~15 mmHg
Distal latency
1) Significance
2) Definition
3) Normal value
1) reflective the integrity of deglutitive inhibition
2) interval between UES relaxation and CDP
3) 4.5 seconds
Panesophageal pressurization
30 mmHg isobaric contour
Type 1 Chicago classification
aka Classic achalasia Impaired relaxation (IRP >15 mmHg) Absent peristalsis (DCI < 100mmHg.s.cm)
Type 2 Chicago classification
IRP > 15mmHg
100% failed peristalsis (DCI < 100mgH.s.cm)
Panesophageal pressurisation ** (>20% of swallows)
Type 3 Chicago classification
aka Spastic achalasia
premature spastic contractions with DCI > 450mmHg.s.cm
IRP > 15mmHg
no normal peristalsis
can be mixed with panesophageal pressurisation
Distal contractile integral
1) Significance
2) Definition
3) Normal value
1) Vigor of the distal esophageal contraction
2) measured between the proximal and distal pressure troughs for the duration of contraction within this region
3) 450 -8000mmHg.s.cm
EGJ outflow obstruction
IRP > 15mmHg
Evidence of peristalsis
Absent contractility
Normal median IRP
100% failed peristalsis (Premature contractions with DCI < 450mmHg.s.cm)
Distal oesophageal spasm
Normal median IRP
DCI >450mmHg.s.cm in >20% on premature contractions
Jackhammer esophagus
at least two swallows with DCI > 8000mmHg.s.cm
Treatment options
Botulin toxin
Pneumatic dilation
Surgical myotomy
POEM
IEM
Ineffective esophageal motility
>50% ineffective swallows weak or failed swallows (DCI<450mmHg)
Oesophageal myotome
1) Adv
2) Disadv
1)
-can be definitive
-most effective
-halts disease progression
2)
Operative morbidity
Hospitalisation
Expensive
Post-tx reflux
Pneumatic dilation
1) Adv
2) Disadv
1) outpatient procedure can be repeated no post-tx reflux potentially long term solution halts disease progress 2) perforation risk 2-4% less effective then myotomy may require successive dilations
Botox
1) Adv
2) Disadv
1) easy, safe, reversible
2) temporary, ineffective, expensive,
does not halt disease progression
may impede myotome
Surgical myotomy
1) open vs lap
2) laparoscopic vs thoracoscopic
1) lap: shorter LOS, less pain, similar outcome
2) lap: shorter procedure, fewer conversions, shorter LOS, better symptomatic outcome
Role of fundoplication
Deceases pathological reflux
Motility disorders of the oesophagus
1) Primary
2) Secondary
1) Achalasia, diffuse oesophageal spasm, non-specific motility disorder
2) Systemic sclerosis, SLE, polymyositis, DM, Chagas disease, polyarteritis nodosa,
