Neurogastroenterology & Motility POST-GRADUATE COURSE 1
POST-GRADUATE COURSE Thursday, 4 June 2015 08:30–12:00 Hall A PGC ESNM Post-Graduate Course: New Standards: Clinical measurement of GI motility and function 001 Pharynx/Esophagus: Assessment of pharyngeal swallow
the pharyngeal phase of swallowing, with the impedance pattern serving as a guideline for analysis of pressure
of patients with GERD either does not suffer from heartburn at all or more commonly has symptoms other
N. ROMMEL KU Leuven, Faculty of Medicine, Neurosciences, Belgium
measurements (8–12). The derived pressure-flow variables define bolus timing, pressure, contractile vigor and bolus presence and are objective markers of deglutitive function. These variables have been validated versus videofluoroscopy and are altered in relation to ineffective swallowing and aspiration risk, which was assessed in adults (12–13) as well as in children (14).
than heartburn. Indeed, gastroesophageal reflux can cause episodes of chestpain that resemble ischemic cardiac pain, without accompanying heartburn or regurgitation. Unfortunately, not only might it be difficult to differentiate chestpain of esophageal origin from cardiac origin, it also is difficult to attribute chest pain to a specific esophageal disorder based on clinical
004 Gastro-Esophageal Reflux: Clinical assessment of patients with reflux symptoms
characteristics of the pain. Thus, a cardiology evaluation is mandatory in patients with angina-like pain. Another symptom reported quite commonly by GERD patients is dysphagia, defined as a perceived impairment of the passage of food from the mouth into the stomach. By the way, dysphagia is troublesome only in a small propor-
Abstract: Swallowing dysfunction or dysphagia has an important impact on the patient’s quality of life since it can lead to a range of significant consequences as aspiration pneumonia, malnutrition, dehydration and food impaction. With a variety of causes, dysphagia affects a broad population from the neonate to the elderly. Improving inefficient swallowing requires a detailed understanding of normal and abnormal deglutition through the use of adequate and objective assessment techniques. The main clinical tools available to study pharyngeal and UES function are videofluoroscopy, UES manometry and Flexible endoscopic evaluation of swallowing FEES (1). Videofluoroscopy, which allows documentation of bolus transport during swallowing and identification of the presence of pharyngeal residue and aspiration, is the most widely applied and accepted technique. However, videofluoroscopy is hampered by radiation exposure, which limits repetitive and long-term measurements, and the fact that anatomical changes do not always correlate with functional characteristics (2). Manometry is hampered by movement of the sphincter and catheter during swallowing and by radial asymmetry of the UES (3). Combining videofluoroscopy with manometry overcomes some of the limitations of each technique, but still involves radiation exposure and manometric parameters correlate poorly with the presence of aspiration (3–7). A recent technique called pressure flow analysis (PFA) combines manometric assessment with impedance measurements to derive variables indicative of the swallow function in
E. V. SAVARINO University of Padua, DISCOG, Italy Abstract: Gastroesophageal reflux disease (GERD) is one of the most common chronic condition in Western Countries, with 10–30% of populations affected by weekly symptoms. Indeed, reflux symptoms are common in primary care and GERD is frequently diagnosed based on symptoms alone, but there is no consensus on the distinction of GERD from dyspepsia, so that these terms may lead to confusion in primary care settings. There is also uncertainty about the extraesophageal manifestations of GERD, coupled with an expanding list of putative extraesophageal disorders, resulting in both over- and underdiagnosis of the disease. According to the Montreal Classification, heartburn is defined as a burning sensation in the retrosternal area (behind the breastbone), whereas regurgitation is defined as the perception of flow of refluxed gastric content into the mouth or hypopharynx. These typical symptoms are considered the hallmarks of reflux disease. A proportion
tion of patients with GERD and resolves in most patients after acid-suppressing therapy. In some cases, underlying symptoms are not apparent until the predominant symptoms are under control. Moreover, other difficulties may arise when a symptom may be nonspecific, hard to monitor, or sporadic. This is the case of atypical extraesophageal GERD syndromes. Indeed, although a great amount has been published on the extraesophageal GERD syndromes, little of this represents high-level original work. Moreover, data suggesting causality are poor and generally limited to cough, laryngitis, asthma, and dental erosions. In the latter cases, it has been emphasized (i) the existence of an association between these syndromes and GERD, (ii) the rarity of extraesophageal syndromes occurring in isolation without a concomitant manifestations of the typical esophageal syndrome, (iii) that these syndromes are usually multifactorial with GERD as one of the several potential aggravating cofactors, and (iv) that data substantiating a beneficial effect of reflux treatments on the extraesophageal syndromes are weak. Thus, partic-
© 2015 THE AUTHORS NEUROGASTROENTEROLOGY & MOTILITY© 2015 JOHN WILEY & SONS LTD N E U R O G A S T R O E N T E R O L . M O T I L . 2 0 1 5 , 2 7 , S U P P L E M E N T 2 , 1 -- 2
1
2 POST-GRADUATE COURSE
ularly in case of atypical extraesophageal GERD syndromes, a symptom-based diagnosis is difficult and further testing (i.e. pH monitoring) is mandatory to detect abnormal parameters and to support the final diagnosis of atypical GERD.
007 Anorectal Function: Clinical assessment of patients with anorectal symptoms G. CHIARIONI University of Verona, Internal Medicine Section A, Italy Abstract: Defecatory disorders (DD) and fecal incontinence (FI) are common, benign conditions with considerable impact on health expenses and quality of life (QOL). Chronic anorectal pain is a less frequent disorder bearing high economic and QOL burden as well. Both
impaired rectoanal function during defecation and/or structural defects of the pelvic floor may be relevant etiology to DD and chronic pain. FI is commonly associated with impairment of one or more anorectal continence mechanisms. Many patients have insufficient knowledge about the availability and effectiveness
the diagnosis of DD is adequate. Therefore, all constipated and pain patients not responding to conservative treatment should be considered for anorectal testing with two tests indicating impaired defecation required to diagnose a DD. The balloon evacuation test (BET) is a reliable screening test of simulated evacuation in which
of treatments for FI and most prefer physicians to ask them directly about FI. Defective stool consistency might be the primary cause of symptoms or may unmask sensorimotor dysfunction of the anorectum in all conditions. A thorough clinical assessment including history and a well performed digital rectal examination
a well lubricated balloon catheter is inserted into the rectum before attempting to expel it in the sitting position. A simple 16 F Foley catheter inflated with 50 mL tepid water has been reported to be effective diagnostic tool. The BET has a high negative predictive value for dyssynergic defecation as defined by paradox-
is key to establish adequate diagnosis and tailor management. Alarm symptoms need to be looked for and investigated. A clinical scenario including a sensation of incomplete evacuation, sensation of blocked evacuation, and pressing in the vagina or around the anus to facilitate defecation is commonly considered specific to DD. However, published studies failed to show that the
ical contraction and/or failure to relax the pelvic floor on straining. Patients with FI should be managed with lifestyle modifications and pharmacotherapy to improve stool consistency. When these measures are not beneficial, anorectal testing to look for potential indication to biofeedback therapy should be considered.
positive and negative predictive value of symptoms for
© 2015 THE AUTHORS
2
NEUROGASTROENTEROLOGY & MOTILITY© 2015 JOHN WILEY & SONS LTD N E U R O G A S T R O E N T E R O L . M O T I L . 2 0 1 5 , 2 7 , S U P P L E M E N T 2 , 1 -- 2
POST-GRADUATE COURSE Thursday, 4 June 2015 08:30–12:00 Hall A PGC ESNM Post-Graduate Course: New Standards: Clinical measurement of GI motility and function 001 Pharynx/Esophagus: Assessment of pharyngeal swallow
the pharyngeal phase of swallowing, with the impedance pattern serving as a guideline for analysis of pressure
of patients with GERD either does not suffer from heartburn at all or more commonly has symptoms other
N. ROMMEL KU Leuven, Faculty of Medicine, Neurosciences, Belgium
measurements (8–12). The derived pressure-flow variables define bolus timing, pressure, contractile vigor and bolus presence and are objective markers of deglutitive function. These variables have been validated versus videofluoroscopy and are altered in relation to ineffective swallowing and aspiration risk, which was assessed in adults (12–13) as well as in children (14).
than heartburn. Indeed, gastroesophageal reflux can cause episodes of chestpain that resemble ischemic cardiac pain, without accompanying heartburn or regurgitation. Unfortunately, not only might it be difficult to differentiate chestpain of esophageal origin from cardiac origin, it also is difficult to attribute chest pain to a specific esophageal disorder based on clinical
004 Gastro-Esophageal Reflux: Clinical assessment of patients with reflux symptoms
characteristics of the pain. Thus, a cardiology evaluation is mandatory in patients with angina-like pain. Another symptom reported quite commonly by GERD patients is dysphagia, defined as a perceived impairment of the passage of food from the mouth into the stomach. By the way, dysphagia is troublesome only in a small propor-
Abstract: Swallowing dysfunction or dysphagia has an important impact on the patient’s quality of life since it can lead to a range of significant consequences as aspiration pneumonia, malnutrition, dehydration and food impaction. With a variety of causes, dysphagia affects a broad population from the neonate to the elderly. Improving inefficient swallowing requires a detailed understanding of normal and abnormal deglutition through the use of adequate and objective assessment techniques. The main clinical tools available to study pharyngeal and UES function are videofluoroscopy, UES manometry and Flexible endoscopic evaluation of swallowing FEES (1). Videofluoroscopy, which allows documentation of bolus transport during swallowing and identification of the presence of pharyngeal residue and aspiration, is the most widely applied and accepted technique. However, videofluoroscopy is hampered by radiation exposure, which limits repetitive and long-term measurements, and the fact that anatomical changes do not always correlate with functional characteristics (2). Manometry is hampered by movement of the sphincter and catheter during swallowing and by radial asymmetry of the UES (3). Combining videofluoroscopy with manometry overcomes some of the limitations of each technique, but still involves radiation exposure and manometric parameters correlate poorly with the presence of aspiration (3–7). A recent technique called pressure flow analysis (PFA) combines manometric assessment with impedance measurements to derive variables indicative of the swallow function in
E. V. SAVARINO University of Padua, DISCOG, Italy Abstract: Gastroesophageal reflux disease (GERD) is one of the most common chronic condition in Western Countries, with 10–30% of populations affected by weekly symptoms. Indeed, reflux symptoms are common in primary care and GERD is frequently diagnosed based on symptoms alone, but there is no consensus on the distinction of GERD from dyspepsia, so that these terms may lead to confusion in primary care settings. There is also uncertainty about the extraesophageal manifestations of GERD, coupled with an expanding list of putative extraesophageal disorders, resulting in both over- and underdiagnosis of the disease. According to the Montreal Classification, heartburn is defined as a burning sensation in the retrosternal area (behind the breastbone), whereas regurgitation is defined as the perception of flow of refluxed gastric content into the mouth or hypopharynx. These typical symptoms are considered the hallmarks of reflux disease. A proportion
tion of patients with GERD and resolves in most patients after acid-suppressing therapy. In some cases, underlying symptoms are not apparent until the predominant symptoms are under control. Moreover, other difficulties may arise when a symptom may be nonspecific, hard to monitor, or sporadic. This is the case of atypical extraesophageal GERD syndromes. Indeed, although a great amount has been published on the extraesophageal GERD syndromes, little of this represents high-level original work. Moreover, data suggesting causality are poor and generally limited to cough, laryngitis, asthma, and dental erosions. In the latter cases, it has been emphasized (i) the existence of an association between these syndromes and GERD, (ii) the rarity of extraesophageal syndromes occurring in isolation without a concomitant manifestations of the typical esophageal syndrome, (iii) that these syndromes are usually multifactorial with GERD as one of the several potential aggravating cofactors, and (iv) that data substantiating a beneficial effect of reflux treatments on the extraesophageal syndromes are weak. Thus, partic-
© 2015 THE AUTHORS NEUROGASTROENTEROLOGY & MOTILITY© 2015 JOHN WILEY & SONS LTD N E U R O G A S T R O E N T E R O L . M O T I L . 2 0 1 5 , 2 7 , S U P P L E M E N T 2 , 1 -- 2
1
2 POST-GRADUATE COURSE
ularly in case of atypical extraesophageal GERD syndromes, a symptom-based diagnosis is difficult and further testing (i.e. pH monitoring) is mandatory to detect abnormal parameters and to support the final diagnosis of atypical GERD.
007 Anorectal Function: Clinical assessment of patients with anorectal symptoms G. CHIARIONI University of Verona, Internal Medicine Section A, Italy Abstract: Defecatory disorders (DD) and fecal incontinence (FI) are common, benign conditions with considerable impact on health expenses and quality of life (QOL). Chronic anorectal pain is a less frequent disorder bearing high economic and QOL burden as well. Both
impaired rectoanal function during defecation and/or structural defects of the pelvic floor may be relevant etiology to DD and chronic pain. FI is commonly associated with impairment of one or more anorectal continence mechanisms. Many patients have insufficient knowledge about the availability and effectiveness
the diagnosis of DD is adequate. Therefore, all constipated and pain patients not responding to conservative treatment should be considered for anorectal testing with two tests indicating impaired defecation required to diagnose a DD. The balloon evacuation test (BET) is a reliable screening test of simulated evacuation in which
of treatments for FI and most prefer physicians to ask them directly about FI. Defective stool consistency might be the primary cause of symptoms or may unmask sensorimotor dysfunction of the anorectum in all conditions. A thorough clinical assessment including history and a well performed digital rectal examination
a well lubricated balloon catheter is inserted into the rectum before attempting to expel it in the sitting position. A simple 16 F Foley catheter inflated with 50 mL tepid water has been reported to be effective diagnostic tool. The BET has a high negative predictive value for dyssynergic defecation as defined by paradox-
is key to establish adequate diagnosis and tailor management. Alarm symptoms need to be looked for and investigated. A clinical scenario including a sensation of incomplete evacuation, sensation of blocked evacuation, and pressing in the vagina or around the anus to facilitate defecation is commonly considered specific to DD. However, published studies failed to show that the
ical contraction and/or failure to relax the pelvic floor on straining. Patients with FI should be managed with lifestyle modifications and pharmacotherapy to improve stool consistency. When these measures are not beneficial, anorectal testing to look for potential indication to biofeedback therapy should be considered.
positive and negative predictive value of symptoms for
© 2015 THE AUTHORS
2
NEUROGASTROENTEROLOGY & MOTILITY© 2015 JOHN WILEY & SONS LTD N E U R O G A S T R O E N T E R O L . M O T I L . 2 0 1 5 , 2 7 , S U P P L E M E N T 2 , 1 -- 2
