Achalasia

Question 1

Difference between HRM and conventional manometry

Answer 1

Number of sensors and spacing between the sensors

Question 2

Clouse Plot (Oesophageal pressure topography)
1)
2) x axis
3) y axis
4) color

Answer 2

1) 3D plotting format
2) time
3) location within esophagus
4) pressure

Question 3

HRM Patient protocol

Answer 3

First: supine, catheter positioned, 10-swallows, each with 5 mol of water
Multiple rapid swallow sequence (MRS):five liquid swallows, 2 mL each, 2-3 seconds apart
Third: upright position, five swallows, 5ml water/saline
Rapid drink challenge: ingestion of 200ml of water as quickly as possible

Question 4

HRM pressure topography landmarks

Answer 4

Anatomic sphincters (UES, LES)
Contractile segments
Transition zone
Contractile deceleration point

Question 5

EPT metrics

Answer 5

integrated relaxation pressure
distal latency
distal contractile integral
contraction vigor
contraction pattern
pressurisation pattern

Question 6

Integrated relaxation pressure

1) Significance
2) Definition
3) Normal value

Answer 6

1) assessing adequacy of OGJ relaxation during swallowing
2) average minimum EGJ pressure for 4 sec of relaxation within 10 seconds of swallowing
3) ~15 mmHg

Question 7

Distal latency

1) Significance
2) Definition
3) Normal value

Answer 7

1) reflective the integrity of deglutitive inhibition
2) interval between UES relaxation and CDP
3) 4.5 seconds

Question 8

Panesophageal pressurization

Answer 8

30 mmHg isobaric contour

Question 9

Type 1 Chicago classification

Answer 9

aka Classic achalasia
Impaired relaxation (IRP >15 mmHg)
Absent peristalsis (DCI < 100mmHg.s.cm)

Question 10

Type 2 Chicago classification

Answer 10

IRP > 15mmHg
100% failed peristalsis (DCI < 100mgH.s.cm)
Panesophageal pressurisation ** (>20% of swallows)

Question 11

Type 3 Chicago classification

Answer 11

aka Spastic achalasia
premature spastic contractions with DCI > 450mmHg.s.cm
IRP > 15mmHg
no normal peristalsis
can be mixed with panesophageal pressurisation

Question 12

Distal contractile integral

1) Significance
2) Definition
3) Normal value

Answer 12

1) Vigor of the distal esophageal contraction
2) measured between the proximal and distal pressure troughs for the duration of contraction within this region
3) 450 -8000mmHg.s.cm

Question 13

EGJ outflow obstruction

Answer 13

IRP > 15mmHg

Evidence of peristalsis

Question 14

Absent contractility

Answer 14

Normal median IRP

100% failed peristalsis (Premature contractions with DCI < 450mmHg.s.cm)

Question 15

Distal oesophageal spasm

Answer 15

Normal median IRP

DCI >450mmHg.s.cm in >20% on premature contractions

Question 16

Jackhammer esophagus

Answer 16

at least two swallows with DCI > 8000mmHg.s.cm

Question 17

Treatment options

Answer 17

Botulin toxin
Pneumatic dilation
Surgical myotomy
POEM

Question 18

IEM

Answer 18

Ineffective esophageal motility

>50% ineffective swallows weak or failed swallows (DCI<450mmHg)

Question 19

Oesophageal myotome

1) Adv
2) Disadv

Answer 19

1)
-can be definitive
-most effective
-halts disease progression
2)
Operative morbidity
Hospitalisation
Expensive
Post-tx reflux

Question 20

Pneumatic dilation

1) Adv
2) Disadv

Answer 20

1)
outpatient procedure
can be repeated
no post-tx reflux
potentially long term solution
halts disease progress
2)
perforation risk 2-4%
less effective then myotomy
may require successive dilations

Question 21

Botox

1) Adv
2) Disadv

Answer 21

1) easy, safe, reversible
2) temporary, ineffective, expensive,
does not halt disease progression
may impede myotome

Question 22

Surgical myotomy

1) open vs lap
2) laparoscopic vs thoracoscopic

Answer 22

1) lap: shorter LOS, less pain, similar outcome

2) lap: shorter procedure, fewer conversions, shorter LOS, better symptomatic outcome

Question 23

Role of fundoplication

Answer 23

Deceases pathological reflux

Question 24

Motility disorders of the oesophagus

1) Primary
2) Secondary

Answer 24

1) Achalasia, diffuse oesophageal spasm, non-specific motility disorder
2) Systemic sclerosis, SLE, polymyositis, DM, Chagas disease, polyarteritis nodosa,

Question 25

Heller’s myotomy

Answer 25

Oesophagomyotomy procedure in wish the oesophageal sphincter muscle is cut

Question 26

POEM procedure

Answer 26

1. enter into submucosa at mid-esophagus
2. creation of submucosal tunnel ~ half of esophageal circumference
3. myotomy from 6cm above EGJ to 3cm distal to entry
4. clip mucosotomy

Question 27

Technical differences between POEM and Heller

Answer 27

No skin incisions
Myotomy of circular muscular layer
No disruption of diaphragmatic hiatus
No concurent anti-reflux procedure