Funksjonell oesophagussykdom

Transkript

1 U N I V E R S I T E T E T I B E R G E N Klinisk institutt 1 Funksjonell oesophagussykdom Jan G. Hatlebakk Med.avd., Gastroseksjonen Klinisk Institutt 1

2 Overlapp mellom funksjonelle magetarmsykdommer: Funksjonelle oesophagussykdommer Irritabel tarm Funksjonell dyspepsi

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4 A. Functional Oesophageal Disorders ROME III A1. Functional heartburn A2. Functional chest pain of presumed oesophageal origin A3. Functional dysphagia A4. Globus

5 A1. Diagnostic Criteria for Functional Heartburn Must include all of the following: 1. Burning retrosternal discomfort or pain 2. Absence of evidence that gastroesophageal acid reflux is the cause of the symptom 3. Absence of histopathology-based esophageal motility disorders Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

6 Brystbrann Klassiske symptomer

7 Brystbrann Klassiske symptomer Funksjonell brystbrann ENRD ph +/- SAP +/-? ikke øsofagitt økt permeabilitet?? Refluks-øsofagitt positive kriterier Barretts oesophagus

8 Avdeling / enhet Exclude GERD!

9 Acid-sensitive oesophagus % time ph < 4.0 = 2.3 SAP = 98.5 %

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11 ph-måling i spiserøret

12 Impedance ph Catheter 17cm 15cm 6 impedance channels 2 ph channels Impedans / phmåling i oesophagus 9cm 7cm 5cm 3cm ph - 5 cm ph at tip Adult with Gastric ph Model ZAN-S62C01E ph-måling i ventrikkel og distale øsofagus Impedans-måling i 6 kanaler i øsofagus Symptom Association Probability (SAP) beregnet fra begge målinger

13 Refluksepisode, mildt sur

14 Bravo 48t ph

15 SI and SAP SAP = 100 p = 100% SAP % viser økt sensitivitet

16 PPI test - Sensitivity Proportion with GERD with positive test % Esomeprazole 20 mg bid Esomeprazole 40 mg od Placebo Days Placebo run-in Study drug started

17 PPI test - Specificity Proportion without GERD with negative test % Esomeprazole 20 mg bid Esomeprazole 40 mg od Placebo Days Placebo run-in Study drug started

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19 A2. Diagnostic Criteria for Functional Chest Pain Must include all of the following: 1. Midline chest pain or discomfort that is not of burning quality. 2. Absence of evidence that gastro-oesophageal reflux is the cause of the symptom 3. Absence of histopathology-based oesophageal motility disorders Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

20 Høyoppløselig (HR) manometri

21 Chest pain of presumed oesophageal origin 30% of patients with angina-type chest pain have normal angiograms Up to 15% have oesophageal disease incl. GORD and motility abnormalities Others may have functional chest pain of presumed oesophageal origin

22 Diffuse Oesophageal Spasm

23 Rapid DES

24 nutcracker

25 DCI distal contractile integral Axial length x duration x amplitude Gives the pressure a volume, a complete measure of hypercontractility

26 Lyngsalpene Volume of rock = height x width x length

27 Nutcracker / Hypertensive Oesophagus Definisjon: gj.snittsamplitude >180 mmhg /DCI >5000 Uklar relasjon til smerter Markør for spasmer??? Hos ca.50% assosiert med patologisk refluks Hos > 50% assosiert med normal syreeksposisjon, men syresensitiv oesophagus (SAP > 95%) Kan bedres med PPI-behandling? Alternativ behandling: NG, nitrater, Ca-antagonister

28 jackhammer

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30 Avdeling / enhet Central processing of stimuli 13 patients, 15 healthy controls No difference in resting EEG or evoked potentials on oesophageal electrical stimulation Hoff DAL, NGM 2014

31 Avdeling / enhet Biomekanikk og blodflow 15 FCP patients and 15 controls Wider distal oesophagus, higher stress Perfusion is comparable DAL Hoff 2010

32 A3. Diagnostic Criteria for Functional Dysphagia Must include all of the following: 1. Sense of solid and / or liquid foods sticking, lodging, or passing abnormally through the oesophagus 2. Absence of evidence that gastroesophageal reflux is the cause of the symptom 3. Absence of histopathology-based esophageal motility disorders Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

33 Large break reaks in the 20mmHg pressure 3-5cm small break >5cm major break Failed if <3cm pressure Large break

34 Large break wo/impedance Flytt rammen opp! Large break

35 A4. Diagnostic Criteria for Globus Must include all of the following: 1. Persistent or intermittent, nonpainful sensation of a lump or foreign body in the throat 2.Occurence of the sensation between meals 3.Absence of dysphagia or odynophagia 4. Absence of evidence that gastroesophageal acid reflux is the cause of the symptom 5. Absence of histopathology-based esophageal motility disorders Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

36 Globus The Graduate Hospital: 751 pasienter med UES manometri over 2.5 år. Pasienter med UESP<30mmHg ekskludert. Normal UESP: 17/650 hadde globus Hypertensiv UES: 28/101 hadde globus 26% hadde abnorm refluks, 39% hos pasientkontroller Corso MJ et al. Dig Dis Sci 1998;43:1513-7

37 Konklusjoner Utredning av funksjonell oesophagussykdom må omfatte både gastroskopi med biopsi, 24t impedans-ph-måling og HR manometri Reflukssykdom i alle dens former, samt primære motilitetsforstyrrelser må utelukkes Uklar avgrensing mellom patologisk motilitet og uvanlige motilitetsfunn Ofte assosiert med hypersensitivitet for ulike stimuli Begrensede terapeutiske muligheter: TCA, SSRI, calsiumantagonister, pregabalin (Lyrica)

38 Avdeling / enhet