3. Anatomy
• The oesophagus begins at the upper
oesophageal sphincter at the level of C6 and
finishes at lower oesophageal sphincter at T11
and is approx 25 cm
8. Indications
• Motility disorders:
i. Achalasia
ii. DES
• Pressure from Extrinsic lesions.
• Assessment of abnormality of:
• i. Zenkers diverticulum
• ii. Cricoid webs
• iii. Cricopharyngeal Achalasia.
16. Technique
• PHARYNX
- One mouthful contrast bolus with high
density(250% w/v).
- Patient is asked to swallow once and stop
swallowing there after.
- This is to get optimum mucosal coating.
- Frontal and lateral view x-ray taken
17. Technique
• ESOPHAGUS
- Single contrast
- Multiple mouthfuls of 80% w/v barium
suspension
- Prone swallow to assess esophageal
contraction.
- Useful in esophageal
compression/disordered motility
18. Technique
• Double contrast
- Contrast high density,low viscosity(200-250%).
- 15-20 ml
- Effervescent powder given with another
mouthful of barium.
- In erect posture
• Pre-procedure administration of anti-spasmodic
42. Indications
• Food bolus/ foreign body impaction
• Evaluation and management
of GERD, including noncardiac chest pain.
• Screening and surveillance of Barrett’s
Esophagus
• Treatment and surveillance of Esophageal
varices
43. Indications
• Evaluation and management
of Dysphagia including dilatation of
esophageal strictures
• Evaluation and management of Odynophagia
• Evaluation and management of esophageal
cancer, including placement of esophageal
stents
• Evaluation of the esophagus after abnormal
imaging studies
44. Contraindications
• Absolute:
- Hemodynamic instability
- Possibility of perforation
• Relative:
- Anticoagulation in the appropriate setting (ie,
esophageal dilation)
- Head and neck surgery
- Pharyngeal diverticulum
45. Technique
• Full history & examination.
• Focus on oral cavity and pharynx, thyroid gland,
cervical and supraclavicular lymph nodes.
• Position : Left lateral decubitus position.
• Moderate sedation: narcotic + bzd.
• Scope inserted into the oropharynx with
visualization of epiglottis and vocal cords.
• Scope advanced through pyriform sinuses and
esophageal lumen.
• Air insufflation
67. Measurements &Technique
• Assessment of LES:
- Mean resting pressure
1. Station pull through: 12-30mmHg
2. Rapid pull through: Higher pressures
due to artefacts
- Also provides information regarding:
1. Total length
2. Intra-abdominal length
3. Location of the sphincter wrt the nares
68. Measurement & Techniques
• Esophageal body:
- To assess the effectivity of peristalsis
- Specific parameters:
1. Peristaltic activity: percentage of initiated
swallows that transmitted successfully. Normal
>80%
2. Amplitude: Avg of pressures generated at
the distal end of the esophagus while
transmitting the peristaltic waves. Normal
>30mmHg
70. High Resolution Impedence
Manometry
• Combination of pressure tomography with
impedance testing
• Advantages:
- Greater accuracy
- Effective continuous recording of motor activity
along the entire length of the esophagus
- No pseudorelaxation
• Colour contour plot with:
- time: X Axis
- esophageal length: Y Axis
74. Definition
• Technique to identify as well as quantify acid
reflux over a period of 24 hrs
• Technique:
-
75. Technique
• Catheter containing one or more solid-state
electrodes in the esophagus
• Electrodes are spaced 5 to 10 cm apart
• Sense fluctuations in the pH between 2 and 7
• Electrodes are connected to a data recorder
that the patient wears for the period of
observation
• There is a digital clock displayed on the
recorder
77. Information obtained
1. Total number of episodes
2. Longest episode of reflux
3. Episodes> 5mins
4. Extent of reflux in upright and supine
positions
78. Interpretation
1. De Meester’s Score > 14.7
2. Total % of time pH < 4:
- Proximal: 1%
- Distal: 4%
3. Correlation of symptom diary with reflux
episodes
80. Impedance pH monitoring
• Basis:
- Detection of reflux events based on a change
in resistance to flow of an electrical currents
b/w electrodes
- Impedance decreases with air and increases
with a liquid bolus
81. Impedance pH monitoring
• Advantages:
- Differentiates b/w acidic and alkaline reflux
- Estimation of the proximal extent of reflux
- Distinction b/w true reflux and the ingestion
of an acidic liquid
• Disadvantage:
- Over estimation of the number of reflux
episodes
- Availability
82. Impedance pH monitoring
• Indication:
- Pts with symptoms despite PPI therapy and
normal distal acid exposure on standard pH
monitoring
84. Basis
• Patent of Medtronic
• Using bilirubin as a marker for bile it records
the frequency and duration of bile exposure in
either the stomach or the esophagus over 24
hrs
• Works on the principle of Spectrophotometry
85. Indications
1. Pts with typical reflux symptoms, who do not
successfully respond to therapy and are not
affected by esophagitis at endoscopy
2. Atypical symptoms and normal endoscopy
3. Patients on follow-up after medical and
surgical therapy
88. Technology
• Based on the “Pulse Echo Technique”
• Aka B Mode/ Gray scale ultrasonography
• Fast frame display: 12 images / second
• Transducer frequencies b/w 5-20 MHz
• 360 degree sector scan perpendicular to the
transducer tip
• Soft tissue penetration b/w 3-12 cms
89. Technique
• Production of acoustic interface b/w
transducer and tissue:
- Water filled balloon
- Transient filling of esophagus with water
• Radial mechanical blind probe for the
assessment of esophageal strictures
90. Indications
• Carcinoma esophagus
- Initial staging
- EUS guided FNAC of LN’s
- Post RT staging
• Benign tumours
• Esophageal cyst
• Achalasia cardia
• Varices
