il sottoscritto edoardo savarino in qualit à di docente dell evento sopra indicato, ai sensi dell...

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


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


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


Hemmink et al. Am J Gastroenterology 2008; 103:2446-53

N=30


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)


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


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


Manometric Diagnosis with Bolus Transit in Manometric Diagnosis with Bolus Transit in GERD PatientsGERD Patients

Pat

ien

ts (

%)


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)

il sottoscritto edoardo savarino in qualit à di docente dell evento sopra indicato, ai sensi dell...

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