Esophageal Function Tests

Question 1

Achalasia presentation

Answer 1

Dysphagia to solids/liquids

Associated weight loss

Question 2

Gold standard test for achalasia

Answer 2

High-res esophageal manometry

Question 3

Manometry - integrated relaxation pressure

Answer 3

Nadir pressure over 4 seconds when EGJ relaxation is expected within a 10-second window after UES relaxation

Question 4

Manometry - distal contractile integral

Answer 4

Assessment of the strength of esophageal smooth muscle contraction

Question 5

Manometry - distal latency

Answer 5

Measure of the timing of esophageal peristalsis

UES relaxation to the contractile deceleration point

Question 6

Type I achalasia manometry

Answer 6

Absent peristalsis, IRP of 10mmHg

Question 7

Type II achalasia manometry

Answer 7

Absent peristalsis with at least 20% of swallows with panesophageal pressurization regardless of IRP

Question 8

Type III (spastic) achalasia manometry

Answer 8

Premature or spastic distal esophageal contractions in at least 20% of swallows

Question 9

Achalasia standard treatment

Answer 9

Distal esophageal myotomy with partial fundoplication

Question 10

Results of myotomy for achalasia

Answer 10

80% (type I)
95% (type II)
60% (type III)

Question 11

POEM how-to

Answer 11

Submucosal tunnel in esophagus approx 10cm proximal to GEJ

Myotomy of circular muscle layers distal extended to 2cm into the cardia

Question 12

Major downside of POEM for achalasia

Answer 12

GERD (up to 40%) since patients don’t have simultaneous reflux procedure

Question 13

Esophageal junction outflow obstruction

Answer 13

Diagnosis based on IRP with exclusion of achalasia

Question 14

Causes of EJOO

Answer 14

• Anatomic abnormality at the cardia (hiatal hernia, disease of esophageal wall)
• Idiopathic with normal anatomy

Question 15

Achalasia contrast esophagram

Answer 15

Bird’s beak

Question 16

Management of non-anatomic EJOO

Answer 16

Invasive interventions only in patients with persistent symptoms and associated weight loss
(significant number of patients report spontaneous resolution over time)

Question 17

Diffuse esophageal spasm

Answer 17

• <10% of esophageal motility disorders
• Uncoordinated contractions of esophagus
• Manometry usually necessary for diagnosis

Question 18

DES symptoms

Answer 18

Chest pain, dysphagia, or both

Question 19

Distal latency DES

Answer 19

Associated with onset of inhibitory myenteric neuron activity after contractions, shorter in patients with DES

Question 20

DES dx guidelines

Answer 20

Normal IRP at LES

Distal latency <4.5s in 20% of wet swallows

Question 21

Medical treatment of DES

Answer 21

Nitrates, sildenafil, TCAs (for noncardiac chest pain)
Diazepam/lorazepam next line
May consider PPI for concomitant GERD

Question 22

Surgical treatment of DES

Answer 22

Laparoscopic or thoracoscopic extended myotomy can be effected in well-selected patients with refractory DES

Question 23

Hypercontractile “nutcracker” esophagus vs. DES

Answer 23

Peristaltic contractions propagate normally, LES relaxes appropriately

Question 24

Manometry of nutcracker esophagus

Answer 24

DCI >8000mmHg s cm in >20% of swallows

Question 25

Medial treatment of nutcracker esophagus

Answer 25

Diltiazem lowers distal peristaltic pressures | Nitrates/sildenafil/TCAs for noncardiac chest pain

Question 26

Ineffective esophageal motility

Answer 26

DCI <450mmHg s cm in 50% of swallows

Question 27

Absent esophageal motility manometry

Answer 27

DCI < 100

Question 28

GERD epidemiology

Answer 28

20% of US population | Patient-reported: pathologic-confirmed: 70%

Question 29

GERD evaluation

Answer 29

1) Trial of PPI | 2) If recurrence, upper endoscopy with esophageal bx

Question 30

Endoscopic findings considered confirmatory for GERD

Answer 30

High-grade esophagitis (Grade C or D) Barrett's metaplasia Peptic stricture

Question 31

GERD non-confirmatory endoscopic findings

Answer 31

Grade B esophagitis: adequate evidence of initiation of medical management Further testing warranted prior to lifetime PPI

Question 32

Demeester score cutoff

Answer 32

14.72 (greater -> abnormal)

Question 33

Measured parameters during 24-hour esophageal pH monitoring

Answer 33

- Percent total time pH <4 - Percent upright time pH <4 - Percent supine time pH <4 - Number of reflux episodes - Number of reflux episodes >=5 minutes - Longest reflux episode (in minutes)

Question 34

Benefit of esophageal impedance monitoring

Answer 34

Evaluation of acid and bile reflux using low AC voltage

Question 35

Type 1 EGJ morphology

Answer 35

No separation between LES and CD

Question 36

Type 2 EGJ morphology

Answer 36

Less than 3cm separation between LES and CD

Question 37

Type 3 EGJ morphology

Answer 37

Greater than 3cm separation between LES and CD

Question 38

Mechanically defective LES

Answer 38

Any one of: - Pressure <6 mmHg - Total length <2cm - Abdominal length <1cm