F/U recent ACG-VGR "High-Resolution Manometry: Thinking beyond the Chicago Classification", @JPandolfinoMD answered Qs that u can encounter when reading #HRM routinely. Q&A posted on ACG circle @AmCollegeGastro. For #GITwitter who may not have access. Here are some (summarized)
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Q: How do u explain achalasia w/ NORMAL IRP. Isn't achalasia characterized by loss of nerves at LES=abnormal IRP?
Dr. Pandolfino: A few explanations-If u start w/ basal LES pressure of 12mmHg- u will naturally have an IRP < 15. Another issue is that HRM catheter...
Q: How do u explain achalasia w/ NORMAL IRP. Isn't achalasia characterized by loss of nerves at LES=abnormal IRP?
Dr. Pandolfino: A few explanations-If u start w/ basal LES pressure of 12mmHg- u will naturally have an IRP < 15. Another issue is that HRM catheter...
2/
...only assesses contact & the mechanics of LES can be such that there is minimal contact-even though there is no relaxation. The HRM catheter is not the best tool to assess relaxation- u need strain measures in the muscle & need to see lengthening in the muscle...
...only assesses contact & the mechanics of LES can be such that there is minimal contact-even though there is no relaxation. The HRM catheter is not the best tool to assess relaxation- u need strain measures in the muscle & need to see lengthening in the muscle...
3/
...Manometry just measures the IBP driving the LES open & if the esophageal pressures are low- u will not see an elevated IRP.
...Manometry just measures the IBP driving the LES open & if the esophageal pressures are low- u will not see an elevated IRP.
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Q: Our center is ONLY doing 10 upright swallows w/ pt seated on a chair (not supine). How does that affect interpretation of the study?
Dr. Pandolfino: I would at least change positions in pts with a high IRP- u ll see that it resolves in many pts...
Q: Our center is ONLY doing 10 upright swallows w/ pt seated on a chair (not supine). How does that affect interpretation of the study?
Dr. Pandolfino: I would at least change positions in pts with a high IRP- u ll see that it resolves in many pts...
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...The new CC 4.0 will come out and state that you need to do manometry in two positions- especially if you see an elevated IRP.
...The new CC 4.0 will come out and state that you need to do manometry in two positions- especially if you see an elevated IRP.
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Q: I have a couple pts w/ mechanical obstruction due to slipped Nissen. HRM was suggestive of EGJOO-is this due to slipped Nissen or true lack of relaxation? Would they benefit from LES Botox?
Dr. Pandolfino: Likely mechanical w/ a tight wrap. I have only seen 2 cases where...
Q: I have a couple pts w/ mechanical obstruction due to slipped Nissen. HRM was suggestive of EGJOO-is this due to slipped Nissen or true lack of relaxation? Would they benefit from LES Botox?
Dr. Pandolfino: Likely mechanical w/ a tight wrap. I have only seen 2 cases where...
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...patients had achalasia when they presented w/ a post-fundo obstruction/dysphagia profile and I have seen 100's of patients with a tight or slipped wrap. It is almost always the wrap-especially if there is evidence of hernia.
...patients had achalasia when they presented w/ a post-fundo obstruction/dysphagia profile and I have seen 100's of patients with a tight or slipped wrap. It is almost always the wrap-especially if there is evidence of hernia.
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Q: Do you think #endoFLIP will be required for the next Chicago classification?
Dr. Pandolfino: NO
Q: How much does an esophageal manometry cost/ barium swallow?
Dr. Pandolfino: Different at different hospitals and centers - ASC-- Manometry is around 250- 600
Q: Do you think #endoFLIP will be required for the next Chicago classification?
Dr. Pandolfino: NO
Q: How much does an esophageal manometry cost/ barium swallow?
Dr. Pandolfino: Different at different hospitals and centers - ASC-- Manometry is around 250- 600
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Q: How do u measure the IRP in pt w/ medium or large hiatal hernia? How would u place the eSleeve box & gastric baseline?
Dr. Pandolfino: I measure it around the LES & CD separately using the gastric marker in the hernia sac for the LES & the gastric marker in the stomach...
Q: How do u measure the IRP in pt w/ medium or large hiatal hernia? How would u place the eSleeve box & gastric baseline?
Dr. Pandolfino: I measure it around the LES & CD separately using the gastric marker in the hernia sac for the LES & the gastric marker in the stomach...
10/
...for the crural diaphragm. Most obstructions in hernia are at the crura-- if you see a high IRP at the LES in a large hernia- it is usually a contact artifact from angulation.
...for the crural diaphragm. Most obstructions in hernia are at the crura-- if you see a high IRP at the LES in a large hernia- it is usually a contact artifact from angulation.
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Q: The problem w/ having multiple metrics to validate EGJOO relevance (FLIP, TBE, RDC, solid meal, etc) is that some may be positive & others negative. Do u use any hierarchical order to decide?
Q: The problem w/ having multiple metrics to validate EGJOO relevance (FLIP, TBE, RDC, solid meal, etc) is that some may be positive & others negative. Do u use any hierarchical order to decide?
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Dr. Pandolfino: Yes-TBE w/ tablet is the best, but a FLIP with a DI >3.5 virtually rules it out. If you have a FLIP during the index endoscopy that has RACs and a DI >3.5- you are done-- they have normal motility.
Dr. Pandolfino: Yes-TBE w/ tablet is the best, but a FLIP with a DI >3.5 virtually rules it out. If you have a FLIP during the index endoscopy that has RACs and a DI >3.5- you are done-- they have normal motility.
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Q: Is there any benefit to doing upright swallows prior to the 10 supine swallows to allow catheter to be placed or to more easily to identify coiling?
Dr. Pandolfino: That is OK- as long as you do both positions and use the provocative swallows- order is not that important.
Q: Is there any benefit to doing upright swallows prior to the 10 supine swallows to allow catheter to be placed or to more easily to identify coiling?
Dr. Pandolfino: That is OK- as long as you do both positions and use the provocative swallows- order is not that important.
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Q: Seems like there are many explanations for ⬆️ IRP that is “fake” (contact artifact, hernia, etc), but what about a falsely low IRP? Have had a few pts w/ clear outflow obstruction on esophagram and/or FLIP & then an IRP of 8 on manometry which I find hard to explain...
Q: Seems like there are many explanations for ⬆️ IRP that is “fake” (contact artifact, hernia, etc), but what about a falsely low IRP? Have had a few pts w/ clear outflow obstruction on esophagram and/or FLIP & then an IRP of 8 on manometry which I find hard to explain...
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...Dr. Pandolfino: Semantics. The low IRP is showing u that the sphincter is relaxed and not touching the catheter- but it may not open well because the sphincter still doesn't relax or the mechanics are off as it may not be elastic due to fibrosis, hypertrophy.
...Dr. Pandolfino: Semantics. The low IRP is showing u that the sphincter is relaxed and not touching the catheter- but it may not open well because the sphincter still doesn't relax or the mechanics are off as it may not be elastic due to fibrosis, hypertrophy.
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Q: Can u speak to the process of endoscopic placement? I am particularly concerned w/ effect of sedation, which meds he uses, timing of the study after sedation & placement.
Dr. Pandolfino: We do this all the time-have not had major issues with crazy measurements...
Q: Can u speak to the process of endoscopic placement? I am particularly concerned w/ effect of sedation, which meds he uses, timing of the study after sedation & placement.
Dr. Pandolfino: We do this all the time-have not had major issues with crazy measurements...
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...Let the patient recover for 60 minutes and they are usually fine.
...Let the patient recover for 60 minutes and they are usually fine.
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Q: What do would u do w/ an image of pseudorelaxation of LES and shortening of the esophagus?
Dr. Pandolfino: It depends on whether the sphincter is relaxing. If not- I measures the IRP through the sphincter and extend the eSleeve.
Q: What do would u do w/ an image of pseudorelaxation of LES and shortening of the esophagus?
Dr. Pandolfino: It depends on whether the sphincter is relaxing. If not- I measures the IRP through the sphincter and extend the eSleeve.
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What is your opinion of the new term POSED for post-bariatric patients?
Dr. Pandolfino: No real opinion-- I think foregut surgery is tough on the esophagus and the esophagus likes to have a wide pen empty stomach to empty into.
What is your opinion of the new term POSED for post-bariatric patients?
Dr. Pandolfino: No real opinion-- I think foregut surgery is tough on the esophagus and the esophagus likes to have a wide pen empty stomach to empty into.
20/
Q: Does sildenafil affect FLIP measurements?
Dr. Pandolfino: Yes- it will reduce motility and increase EGJ-DI slightly during distention
Q: Does sildenafil affect FLIP measurements?
Dr. Pandolfino: Yes- it will reduce motility and increase EGJ-DI slightly during distention
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Q: Does he also go with a cut off of 5 cm for TBS abnormality or follow some other cut off for abnormal TBS?
Dr. Pandolfino: Yes- I use 5 cm as a cut-off. But to be honest- I like to see the esophagus empty at 5 minutes to feel like the patient is going to do well.
Q: Does he also go with a cut off of 5 cm for TBS abnormality or follow some other cut off for abnormal TBS?
Dr. Pandolfino: Yes- I use 5 cm as a cut-off. But to be honest- I like to see the esophagus empty at 5 minutes to feel like the patient is going to do well.
22/
Q: Please elaborate on interpretation of % liquid and viscous impedance done during him.
Dr. Pandolfino: Don't do viscous anymore- never helped. Impedance needs to evolve more and now I use it as a loos guide.
Q: Please elaborate on interpretation of % liquid and viscous impedance done during him.
Dr. Pandolfino: Don't do viscous anymore- never helped. Impedance needs to evolve more and now I use it as a loos guide.
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Q: What are ur concerns for LES fibrosis induced by botox?
Dr. Pandolfino: I do have concerns-I have seen a lot of injury & would rather use viagra or provide definitive Rx. My only perforation was in a pt that had multiple BoTox injections & they had fibrosis ➡️ popped open.
Q: What are ur concerns for LES fibrosis induced by botox?
Dr. Pandolfino: I do have concerns-I have seen a lot of injury & would rather use viagra or provide definitive Rx. My only perforation was in a pt that had multiple BoTox injections & they had fibrosis ➡️ popped open.
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Dysphagia for liquids only. How do you treat?
Dr. Pandolfino: Make sure you get a speech path eval-- this is odd for just the esophagus -- if they can handle solids.
Dysphagia for liquids only. How do you treat?
Dr. Pandolfino: Make sure you get a speech path eval-- this is odd for just the esophagus -- if they can handle solids.
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Post-prandial HRM, do u complete ur protocol, stop, & then have them eat, & replace catheter?
Dr. Pandolfino: No-they eat w/ catheter in place-they tolerate it & I don't worry about the drift as u r looking for major pressure changes.
Post-prandial HRM, do u complete ur protocol, stop, & then have them eat, & replace catheter?
Dr. Pandolfino: No-they eat w/ catheter in place-they tolerate it & I don't worry about the drift as u r looking for major pressure changes.
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When you have a patient who you think is evolving to a major disorder but manometry/TBE is not definitive, when do you bring them back from another study? 6 months, 12 months? Symptom evolution?
Dr. Pandolfino: 6 months- usually for an esophagram
When you have a patient who you think is evolving to a major disorder but manometry/TBE is not definitive, when do you bring them back from another study? 6 months, 12 months? Symptom evolution?
Dr. Pandolfino: 6 months- usually for an esophagram
27/
3D-HRM could be useful in confirming achalasia, in inability to study EGJ w/ standard catheter.
Dr. Pandolfino: I find 3D assessment not that useful-it has a lot of contact artifact-just my opinion.
For solid swallows, what do u use in your protocol?
Dr. Pandolfino: Crackers
3D-HRM could be useful in confirming achalasia, in inability to study EGJ w/ standard catheter.
Dr. Pandolfino: I find 3D assessment not that useful-it has a lot of contact artifact-just my opinion.
For solid swallows, what do u use in your protocol?
Dr. Pandolfino: Crackers
28/
Why should endoFLIP not replace HRM for suspected Achalasia after endoscopy?
Dr. Pandolfino: I think it can in unequivocal cases-but u have to be careful in equivocal cases. Normal esophagus, borderline DI 1-2 & some contractions in esophagus-just get a mano to make sure.
Why should endoFLIP not replace HRM for suspected Achalasia after endoscopy?
Dr. Pandolfino: I think it can in unequivocal cases-but u have to be careful in equivocal cases. Normal esophagus, borderline DI 1-2 & some contractions in esophagus-just get a mano to make sure.
29/
Do you think that a small hiatal hernia or Schatzki ring really can cause EGJOO?
Dr. Pandolfino: Yes-a small hernia can & Tom Demeester described this on barium studies years ago. They get a pinched cardia & sometimes u just miss it but see it when you change positions as ...
Do you think that a small hiatal hernia or Schatzki ring really can cause EGJOO?
Dr. Pandolfino: Yes-a small hernia can & Tom Demeester described this on barium studies years ago. They get a pinched cardia & sometimes u just miss it but see it when you change positions as ...
30/
...it gets worse. Rings have to have a sufficient diameter change-less than 15mm as u can see a ramp up of the IBP. I think subtle stenosis from transmural inflammation at the LES in GERD can cause fibrosis & poor opening & that can also be associated w/ a small hernia.
...it gets worse. Rings have to have a sufficient diameter change-less than 15mm as u can see a ramp up of the IBP. I think subtle stenosis from transmural inflammation at the LES in GERD can cause fibrosis & poor opening & that can also be associated w/ a small hernia.
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Pt has jackhammer esophagus, EGJOO, w/ symptoms of chest pain, dysphagia. Persistent chest pain after myotomy. What’s your recommendation?
Dr. Pandolfino: Rethink the diagnosis & try sildenafil...
Pt has jackhammer esophagus, EGJOO, w/ symptoms of chest pain, dysphagia. Persistent chest pain after myotomy. What’s your recommendation?
Dr. Pandolfino: Rethink the diagnosis & try sildenafil...
32/
...I would also look to see if the pt stills has a spastic segment that the myotomy has not addressed. Sometimes they blow out the myotomy if they still have contractions.
...I would also look to see if the pt stills has a spastic segment that the myotomy has not addressed. Sometimes they blow out the myotomy if they still have contractions.
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In endoFLIP, it is regularly performed during endoscopy, what type of sedation medications should be administered?
Dr. Pandolfino: Sedation should not alter FLIP assessment. It is a secondary response and we have not seen major issues with moderate sedation or propofol.
In endoFLIP, it is regularly performed during endoscopy, what type of sedation medications should be administered?
Dr. Pandolfino: Sedation should not alter FLIP assessment. It is a secondary response and we have not seen major issues with moderate sedation or propofol.
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Pseudoachalasia vs Achalasia on HRM?
Dr. Pandolfino: Need pharmacologic assessment with amyl nitrite- otherwise it is difficult and based on clinical presentation and findings- in the surgical naïve patient- EUS can be helpful.
Pseudoachalasia vs Achalasia on HRM?
Dr. Pandolfino: Need pharmacologic assessment with amyl nitrite- otherwise it is difficult and based on clinical presentation and findings- in the surgical naïve patient- EUS can be helpful.
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We have Manoscan. Pt w/ high IRP (180) and 90% failed peristalsis, the software only calls EGJOO rather than achalasia. Is this a software issues, what else should I consider?
Dr. Pandolfino: That software is a tree algorithm- it is wrong about 15% of the time.
We have Manoscan. Pt w/ high IRP (180) and 90% failed peristalsis, the software only calls EGJOO rather than achalasia. Is this a software issues, what else should I consider?
Dr. Pandolfino: That software is a tree algorithm- it is wrong about 15% of the time.
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In young pts w/ rumination disorder-have you ever placed PEG for nutritional support while they r receiving cognitive therapy?
Dr. Pandolfino: No-would be nervous about PEG staying in place if someone was ruminating too much. They literally push the stomach up in the chest.
In young pts w/ rumination disorder-have you ever placed PEG for nutritional support while they r receiving cognitive therapy?
Dr. Pandolfino: No-would be nervous about PEG staying in place if someone was ruminating too much. They literally push the stomach up in the chest.
