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Il sottoscritto EDOARDO SAVARINO
in qualità di docente dell’evento sopra indicato, ai sensi dell’art. 3.3 sul Conflitto di Interessi, pag. 17
del Reg. Applicativo dell’Accordo Stato-Regioni del 5/11/09, per conto del provider I&C srl
dichiarache negli ultimi due anni
non ha avuto rapporti con soggetti portatori di interessi commerciali in campo sanitario
NOME E NUMERO DEL PROVIDER: I&C SRL - 7598-ECM N°: 11005555TITOLO: XIV CONGRESSO NAZIONALE GISMADSEDE: VENEZIA-MESTREDATA: 18-19 MARZO 2011
Impatto delle Tecnologie Impatto delle Tecnologie sulla gestione clinica:sulla gestione clinica:
pH e Manometry-ImpedancepH e Manometry-Impedance
Dott. Edoardo V. Savarino
Dipartimento di Medicina Interna, Clinica di Gastroenterologia con
Endoscopia Digestiva, Università di Genova (Resp. Prof. V. Savarino)
NEW NEW TECHNOLOGIESTECHNOLOGIES
Esophageal pH monitoring without catheter
3 cm
5 cm
7 cm
9 cm
15 cm
17 cm
pH - 5 cm
6 impedance channels
1 pH channel
Combined impedance-manometry
Impedance MonitoringImpedance Monitoring
Kahrilas PJ.
Impedance Monitoring: When?Impedance Monitoring: When?► Evaluation of patients with difficult symptoms Evaluation of patients with difficult symptoms
► Evaluation of symptomatic patients despite PPI therapy Evaluation of symptomatic patients despite PPI therapy
► Evaluation of atypical GERD (Evaluation of atypical GERD (Correlate acid & nonacid GER episodes to Correlate acid & nonacid GER episodes to Sx and Sx and quantify proximal extent of GER)quantify proximal extent of GER)
► Pre and Post-operative evaluation of patients considered for surgery Pre and Post-operative evaluation of patients considered for surgery
► Evaluation of GERD in infants and pediatric patientsEvaluation of GERD in infants and pediatric patients
► Evaluation of new medical or endoscopic therapies for GERDEvaluation of new medical or endoscopic therapies for GERD((Baclofen, Esophyx, Arbaclofen, Lesogaberan etc.Baclofen, Esophyx, Arbaclofen, Lesogaberan etc.))
Cough – Asthma – Laryngitis – Hoarseness – Cough – Asthma – Laryngitis – Hoarseness – Bronchitis - Dysfonia – Interstitial Lung Disease Bronchitis - Dysfonia – Interstitial Lung Disease
Non-Cardiac Chest Pain – Disphagia – Globus Non-Cardiac Chest Pain – Disphagia – Globus
Efficacy of Medical Therapy – Correlate Acid & Efficacy of Medical Therapy – Correlate Acid & Non-Acid GER to Sx – Absence of abnormal GERNon-Acid GER to Sx – Absence of abnormal GER
Pathological acid exposure – Symptom-reflux Pathological acid exposure – Symptom-reflux Association – Efficacy of surgery Association – Efficacy of surgery
Pathological non-acid exposure – Nocturnal apnea Pathological non-acid exposure – Nocturnal apnea
Main Diagnostic AdvantageMain Diagnostic Advantage
Does patient have a reflux disease?Does patient have a reflux disease?
Positive Symptom Association Negative Symptom Association
Identify Non-Acid Reflux Disease
Identify Functional Diseases or search for other causes
MII-pH Impedance MonitoringIn case of normal acid exposure
Clinical Utility of Impedance-pH in NERD patientsClinical Utility of Impedance-pH in NERD patients
Savarino E et al. Am J Gastroenterology 2008;103:1-9
The Added Value of Impedance-pH to Rome III The Added Value of Impedance-pH to Rome III Criteria in NERD patients (N=219)Criteria in NERD patients (N=219)
% o
f p
atie
nts
Savarino E et al. Dig Liv Dis 2011; March 2
NARD3% 10%
Rome Criteria 3 ½ Rome Criteria 3 ½
Kahrilas PJ et al. Am J Gastroenterology 2010;747:756
Clinical Utility of Impedance-pH in EE patientsClinical Utility of Impedance-pH in EE patients
EE Patients(N = 58)
Abnormal Acid Exposure Time 47 (81%)
Normal Acid Exposure Time 11 (19%)
Positive SAP44 (76%)
Negative SAP3 (5%)
Positive SAP10 (17%)
Negative SAP 1 (2%)
Savarino E et al. Am J Gastroenterology 2010; 105:1053-61
Clinical Utility of Impedance-pH in EE patientsClinical Utility of Impedance-pH in EE patients
Frazzoni M et al. APT 2011; 33:601-606
“Gastric acid secretion persists despite ongoing PPI therapy and activated
pepsins may well be present in weakly acidic refluxes. Therefore, they may be
responsible for mucosal damage. Therapeutic interventions in patients with PPI-
resistant reflux oesophagitis should be tailored on the basis of impedance–pH-
monitoring results”
Impedance-pH and overlap syndromesImpedance-pH and overlap syndromes
Savarino E et al. Gut 2009; 58:1185-1191
Impedance-pH and overlap syndromesImpedance-pH and overlap syndromes
* = p <0.01
*
**
*
% o
f p
atie
nts
HE FHNERD NERD
Savarino E et al. Gut 2009; 58:1185-1191
Impedance-pH and new drugsImpedance-pH and new drugs
*p<0.05
**
**
Impedance-pH and new drugsImpedance-pH and new drugs
Impedance-pH and surgeryImpedance-pH and surgery
Impedance-pH and surgeryImpedance-pH and surgery
Patients selection: 15 had erosive esophagitis 16 had non-erosive reflux disease
↓ Number of total, acid and weakly acidic reflux episodes↓ Acid exposure time, liquid and mixed reflux events
↓ Gatric belching, but ↑ Supragastric belching16 Patients were asymptomatic
15 Patients were symptomatic, but with negative SI for acid or weakly acidic reflux
Laparoscopic Nissen Fundoplication
Impedance-pH and surgeryImpedance-pH and surgery
No symptom was registered during the study performed after intervention
38 were totally asymptomaticSubtotal symptom remission was
reported by two patients, one with a postoperative heartburn score of 1
(3 before intervention) and one with a post-operative regurgitation score of 1
(3 before intervention)
Impedance-pH: On or Off-PPI Therapy?Impedance-pH: On or Off-PPI Therapy?
Twice-daily PPI Therapy for at least
2 months
Impedance-pH Testing On
Therapy
Impedance-pH: On or Off-PPI Therapy?Impedance-pH: On or Off-PPI Therapy?
Hemmink et al. Am J Gastroenterology 2008; 103:2446-53
N=30
Impedance-pH: On or Off-PPI Therapy?Impedance-pH: On or Off-PPI Therapy?
Modified by Tutuian R. J Gastrointestin Liver Dis 2009; 1:9-10
Impedance
Impedance-pH as the gold standard to test if the
patient has or not GERD in the first place
Impedance-pH as the gold standard to clarify the relationship between symptoms and reflux
Off Therapy On Therapy
History of Erosive esophagitis or Barrett EsophagusPrevious positive conventional pH monitoring
IEM – ineffective esophageal motilityDES – distal esophageal spasmLES – lower esophageal sphincter
Spechler & Castell. Gut 2001; 49:145-51
Definition of Motility AbnormalitiesDefinition of Motility Abnormalities
Esophageal body LES resting pressure LES residual pressure
Achalasia 100% aperistalsis elevated / normal elevated / normal
IEM >30% ineffective contractions normal / low normal
DES >20% simultaneous swallows normal / elevated normal
Normal < 30% ineffective normal normal< 20% simultaneous
Nutcracker normal; DEA >180mmHg normal / elevated normal / elevated
Hypertensive LES normal > 45 mmHg elevated / normal
Poorly relaxing LES normal normal > 8 mmHg
Hypotensive LES normal < 10 mmHg normal
MeaningMeaningof esophageal motilityof esophageal motility
abnormalities ?abnormalities ?
Esophageal Function TestingEsophageal Function TestingCombined Impedance-Manometry Comprehensively Assesses Esophageal FunctionCombined Impedance-Manometry Comprehensively Assesses Esophageal Function
Impedance-Manometry TestingImpedance-Manometry Testing
LES
5cm
10cm
15cm
20cm
5cm
10cm
15cm
20cm
Simren et al. Gut 2003; 52:784-790
Video-fluoro vs. ImpedanceVideo-fluoro vs. Impedance
r = 0.94
Bolus TransitBolus TransitComplete bolus transit Bolus retention at 15cm
20 cm
15 cm
10 cm
5 cm
2 cm
Patients with esophageal Patients with esophageal motility abnormalitiesmotility abnormalities
350 patients350 patients Females 220 (63%), males 130 (37%)Females 220 (63%), males 130 (37%) Age: mean 53.5 years, range 12-86 yearsAge: mean 53.5 years, range 12-86 years
Tutuian R et al. Am J Gastroenterology 2004; 99:1011-9
Percentage of Patients with normal bolus transit for Percentage of Patients with normal bolus transit for liquid based on manometric diagnosis (n=350) liquid based on manometric diagnosis (n=350)
Tutuian R et al. Am J Gastroenterology 2004; 99:1011-9
Impedance-manometry classification Impedance-manometry classification of motility abnormalitiesof motility abnormalities
MildMild ModerateModerate SevereSevere
AchalasiaScleroderma
Nutcracker
Hypertensive LES
Hypotensive LES
Poor relaxing LES
IEM
DES
Pressure only Pressure and Transit
Tutuian R et al. Am J Gastroenterology 2004; 99:1011-9
Frequency of bolus retention at different Frequency of bolus retention at different levels in the esophagus (levels in the esophagus (n=67 patients) n=67 patients)
(Bread)(Bread)
20
15
10
5
2
Chest-pain Dysphagia GERD
% swallows with bolus retention
p<0.05 at each level
40% 30% 20%10% 0% 10%20% 30% 40% 40% 30% 20%10% 0% 10%20% 30%40%40% 30% 20%10% 0% 10%20% 30%40%
DDW 2007, Washington, USA
Manometric Findings in 755 GERD Patients and 48 HVsManometric Findings in 755 GERD Patients and 48 HVs
N=48N=48 N=70N=70 N=239N=239 N=340N=340 N=106N=106
Simile prevalenza di Simile prevalenza di IEMIEM tra HV e tra HV e FHFH
AUMENTO AUMENTO
DELL’INCIDENZA DI DELL’INCIDENZA DI IEMIEM CON L’AUMENTARE CON L’AUMENTARE
DELLA SEVERITA’ DELLE DELLA SEVERITA’ DELLE LESIONILESIONI
FISMAD 2011, Torino, Italy
Bolus Transit alterato in Bolus Transit alterato in Pazienti con lesioni visibili Pazienti con lesioni visibili endoscopicamente endoscopicamente
Valori simili tra FH e NERDValori simili tra FH e NERD
Bolus Transit for Liquid Swallows in GERD PatientsBolus Transit for Liquid Swallows in GERD Patients
FISMAD 2011, Torino, Italy
Manometric Diagnosis with Bolus Transit in Manometric Diagnosis with Bolus Transit in GERD PatientsGERD Patients
Pat
ien
ts (
%)
FISMAD 2011, Torino, Italy
Future Issues to be ElucidatedFuture Issues to be Elucidated
The impact of Bolus Transit assessment in patients undergoing esophageal surgery (Fundoplication, Heller Miotomy, Trans-oral esophageal diverticulectomy etc.)
The diagnostic utility of Bolus Transit assessment in patients with non-obstructive dysphagia (functional dysphagia etc.)
The impact of Bolus Transit assessment in studies aimed at testing future drugs for improving gastro-esophageal emptying (Bolus transit time)