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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
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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
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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
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Michael F. Vaezi, MD, PhD, MSc(Epi), FACG
ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology
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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
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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
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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
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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
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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
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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
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Michael F. Vaezi, MD, PhD, MSc(Epi), FACG
ACG 2015 Nashville Regional Postgraduate Course Copyright 2015 American College of Gastroenterology
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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
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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
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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
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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
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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
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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
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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
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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