New Developments in New Developments in Gastroenterology at West HertsGastroenterology at West Herts

High Resolution oesophageal High Resolution oesophageal manometry and 24 hour pH studiesmanometry and 24 hour pH studies

Dr Mark FullardDr Mark Fullard

Consultant GastroenterologistConsultant Gastroenterologist

BackgroundBackground

• Trained in South East Thames RegionTrained in South East Thames Region

• Research at St George’s Hospital, LondonResearch at St George’s Hospital, London

• MD 2008 MD 2008 – ‘‘Studies in Gastro-oesophageal reflux disease with Studies in Gastro-oesophageal reflux disease with

special emphasis on disease progression’special emphasis on disease progression’

• Appointed as consultant at West Herts April 2008Appointed as consultant at West Herts April 2008

• Special interest in oesophageal disease and Special interest in oesophageal disease and oesophageal physiology. oesophageal physiology.

Lower Esophageal Sphincter

Upper Esophageal Sphincter

Stomach

Esophageal Body

Epiglottis

Pharynx

What is oesophageal manometry?What is oesophageal manometry?

• MeasuresMeasures– Upper oesophageal Upper oesophageal

sphincter pressure sphincter pressure and relaxationand relaxation

– Lower oesophageal Lower oesophageal sphincter pressure sphincter pressure and relaxationand relaxation

– Motor function of Motor function of oesophageal bodyoesophageal body

• Pass catheter Pass catheter through nose into through nose into oesophagus and oesophagus and stomachstomach

• Pressure sensors Pressure sensors along catheter along catheter measure function of measure function of oesophagus in oesophagus in response to response to swallows of waterswallows of water

How is it done?How is it done?

• Conventional Conventional manometrymanometry– 5-8 pressure sensors 5-8 pressure sensors

along catheteralong catheter

How is it done?How is it done?

• High Resolution ManometryHigh Resolution Manometry– 36 circumferential pressure sensors placed 36 circumferential pressure sensors placed

along catheteralong catheter

What is pH study?What is pH study?

Digitrapper pH 100

1 channel

Digitrapper pH 400

4 channels + LES perfusion port

1 or 4 channel 24 h pH recorder

LES

UES

Single channelpH Catheter

Two channelspH CatheterpH sensor

5cm above proximal LES border

pH sensorapprox. 2-3 cm below UES

For ENT positionning:Proximal pH sensoris placed approx. 1 cmabove UES

15 cm between sensors

Indications for proceduresIndications for procedures

• ManometryManometry– Dysphagia with Dysphagia with

normal OGDnormal OGD– Unexplained non Unexplained non

cardiac chest paincardiac chest pain– For patients For patients

considered for anti-considered for anti-reflux surgeryreflux surgery

– Prior to a pH studyPrior to a pH study

• 24 Hr pH study24 Hr pH study– Patients with Patients with

symptoms of reflux symptoms of reflux not responding to not responding to PPIPPI

– Patients with normal Patients with normal OGD and symptoms OGD and symptoms that that maymay be due to be due to refluxreflux

– Patients being Patients being considered for anti-considered for anti-reflux surgeryreflux surgery

‘‘The old systemThe old system’’

• Referred to St Mark’s, UCLReferred to St Mark’s, UCL

• Travel to LondonTravel to London

• Waiting time recently up to 4 monthsWaiting time recently up to 4 months

• West Herts physicians and surgeons West Herts physicians and surgeons combined sent about 80 in last yearcombined sent about 80 in last year

‘‘The New System’The New System’

• Done by meDone by me• HHGHHHGH• Tuesday pmTuesday pm• Doing 3 patients per Doing 3 patients per

weekweek• Expect to do 80-100 Expect to do 80-100

per yearper year• Aim to do within 6 Aim to do within 6

weeksweeks

• Started 2 weeks agoStarted 2 weeks ago

• Take referrals fromTake referrals from– GI colleaguesGI colleagues– SurgeonsSurgeons– Respiratory Respiratory – ENTENT– GPsGPs

Case studyCase study

• Second patientSecond patient

• 28 year old man 28 year old man

• Two years intermittent dysphagia to solids and Two years intermittent dysphagia to solids and liquidsliquids

• OGD normalOGD normal

• Barium swallowBarium swallow– ‘‘No mucosal lesion, tertiary contractions, abnormal No mucosal lesion, tertiary contractions, abnormal

lower oesophagus, not achalasia’lower oesophagus, not achalasia’

• Had high resolution manometry within 2 weeks of Had high resolution manometry within 2 weeks of referralreferral

Patient Normal study

No relaxation of LOS on swallowing LOS relaxes on swallowing

Well propagated swallowSimultaneous, non-propagated weak swallow

Diagnosis = Achalasia

SummarySummary

• New ServiceNew Service

• Useful applicationsUseful applications

• Local service been repatriated from London Local service been repatriated from London teaching hospitalsteaching hospitals

• Less travelling for patientsLess travelling for patients

• Quicker serviceQuicker service

• One of the increasing number of centres One of the increasing number of centres doing high resolution manometry as a doing high resolution manometry as a routineroutine

SummarySummary

• Happy to receive referralsHappy to receive referrals– Will see in clinic firstWill see in clinic first

• Happy to discuss over phone or by e-mailHappy to discuss over phone or by e-mail

mark.fullard@whht.nhs.uk

Tel – 01442 287060