ESOPHAGEAL PHYSIOLOGIC TESTING: Why When HowWhy,...

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

ESOPHAGEAL PHYSIOLOGIC TESTING:

Why When HowWhy, When, How and Then What?

Michael F. Vaezi, MD, PhD, MSc(Epi), FACGProfessor of Medicine and Otolaryngology

Clinical DirectorClinical DirectorDivision of Gastroenterology, Hepatology and Nutrition

Vanderbilt University Medical Center

Esophageal Function

• Barrier for GERD

• Transfer food

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

1

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

GERD is a condition which develops when the reflux of stomach content causes troublesome

symptoms and/or complications

GERD

Extra-esophageal Syndromes

SymptomaticSyndromes

• Typical refluxd

Syndromes withEsophageal Injury• Reflux esophagitis

EstablishedAssociation

• Reflux cough

ProposedAssociation

• Sinusitis

Esophageal Syndromes

syndrome

• Reflux chest painsyndrome

• Reflux stricture

• Barrett's esophagus

• Adenocarcinoma

g

• Reflux laryngitis

• Reflux asthma

• Reflux dentalerosions

• Pulmonaryfibrosis

• Pharyngitis

• Recurrent otitismedia

INDICATIONS FOR TESTING

• Lack of response to therapy

– Assess compliance

– Reflux related cause for pts’ continued sx’s

• Dysphagia, chest pain

Ph i l i t f d li ti• Physiologic assessment pre-fundoplication

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

2

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

DIAGNOSTIC TESTS

• PPI trial

• EGD• EGD

• Barium swallow

• Manometry (old and new)

• Ambulatory MonitoringCatheter wireless– Catheter, wireless

• Pepsin

• Mucosal Impedance

STEP DOWN

PPI - BID

H2RA’s - BID

H2RA’s-q dayA t id

PPI’s - q day

AntacidsLife Style Modification

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

3

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

Endoscopic Findings

Normal Esophagitis Barrett’s

81% 19% 0%81% 19% 0%

Fletcher and Vaezi, Laryngoscope 2011

90% grade A/B

Kavitt and Vaezi, Laryngoscopy 2013

38% hiatal hernia

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

4

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

5

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

100

150mmHg

50

0

30

Ambulatory Monitoring

– Acid (pH)

C th t b d• Catheter based

• Wireless (Bravo)

• Restech

– Non/weakly acidy

• Bilitec

• Impedance

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

6

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

pH Monitoring

Hypopharyngeal

Proximal Esophageal

Distal Esophageal

Proximal and Distal Esophageal Acid Reflux

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

7

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

Hypopharyngeal Acid Reflux

ACID REFLUX IN GERD SPECTRUM

25% 23%

10%

15%

20%

%

7%

15% 15%

Ph< 4

0%

5%

CONTROL NERD GERD uBE cBE

2%

Vaezi and Richter. Gastroenterology 1996; 111:1192-99

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

8

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

pH monitoring in sx’tic pts on PPI therapy

pH

< 4

25

30%

Dis

tal T

otal

Tim

e

5

10

15

20

Upper limit of normal

(69%) (93%) (70%) (99%)

5.5

Vaezi. Am J Gastroenterol 2005;100:283-289.

0

QD

ATYPICAL GERD(n = 115)

BIDQD BID

TYPICAL GERD(n = 135)

OROPHARYNGEAL PH

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

9

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

Oropharyngeal probe

Distal Esophageal bprobe

Sun and Vaezi. Laryngoscope 2009

Weiner and Vaezi. J voice 2009

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

10

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

Oropharyngeal pH Monitoring vs TraditionalTime to Equilibrium pH

Yuksel and Vaezi. NGM 2013; 25: e315-e323

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

11

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

12

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

Antegrade Bolus Movement

Retrograde Bolus Movement

Silny et al. J Gastrointest Motil 1993;5:107-122.Simren et al. Gut 2003;52:784-790.

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

13

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

MII-pH in GERD Refractory to PPI BID

24-hr ambulatory MII-pH

Symptomatic pts(N=144)

Abnl Non-acid reflux Inadequate Acid Supp(Di l id 1 6%)

Normal

Mainie et al. Gut 2006; 55:1398-1402.

(37%) (Distal acid > 1.6%)(11%)

(52%)

+’ve Symptom Index(N=8)

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

14

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

Role of Impedance

• No significant overall relationship between

total # of impedance events and

physiologic parameters

Kavitt et al, DDW 2012

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

15

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

Symptom Analysis

Symptom index (SI): > 50%

# reflux related sx episodes X 100%# reflux related sx episodes

Total # of symptom episodes

Symptom sensitivity index (SSI): >10%

# reflux related sx episodes

Total # of reflux episodes

X 100%

X 100%

Symptom association probability

+Symptoms

-

Reflux+ -

R+S+

R+S-R-S+

R-S-

SI > 50%

SAP > 95%

R+S+R-S+R-S-

supine mealR+S-

Kavitt and Vaezi, Gastroenterology 2012

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

16

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

Audio Recording and pH Monitoring

Kavitt and Vaezi, Gastroenterology 2012

Most Cough Events Are Not Reported

Kavitt and Vaezi, Gastroenterology 2012

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

17

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

Old Technology

Ambulatory Esophageal pHAmbulatory Testing

1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020

Winkelstein JAMA 1935

Kantrowitz Gast ro 1969

Bernstein Gastro 1968

Tuttle Ann Intern Med 1961

Tuttle Proc Soc Exp Biol Med 1958

Miller Arch Surg 1964

Miller Surg Clin N Am 1967

Ambulatory Testing

BravoWirelessSpencer 1969Patrick 1970

Woodard 1970

BravoWireless

Impedance

Pharyngeal pH probe

Limitations of Diagnostic Tests

• Current diagnostic testing suboptimal:

– Limited sensitivity and specificity

– Constrained by measuring reflux

• Single time point (1- or 2-day duration)

• Specific location (5-cm above LES)

• Measure presence of reflux rather than long-term mucosal consequence of GERD

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

18

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

Mucosal Impedance (MI)

Mucosal Impedance (MI) Catheter

Endoscope

Impedance sensors length Esophagitis site

Yuksel and Vaezi, CGH 2012

MI in GERD and Non-GERD

Ates and Vaezi, Gastroenterology 2015

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

19

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

4400

MIPre- and Post-Therapy

3600

1900

39002400

1300

Ates and Vaezi, Gastroenterology 2015

Achalasia

E / H

E+

E-/pH+

E-/pH-Non-GERD

GERD

EoE

Ates and Vaezi, Gastroenterology 2015

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

20

Michael F. Vaezi, MD, PhD, MSc(Epi), FACG

DIAGNOSTIC TESTS

• PPI trial

• EGD• EGD

• Barium swallow

• Manometry (old and new)

• Ambulatory MonitoringCatheter wireless– Catheter, wireless

• Pepsin

• Mucosal Impedance

ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology

21