So, this is the question, is 48-year-old man with refractory heartburn not responding to PPI therapy? And this patient's looking for some alternative measures for treatment, taking omeprazole 40 milligram twice daily with ongoing severe heartburn, one centimeter hiatal hernia, and Los Angeles A esophagitis. So next, if we have the poll, you'll see the different options that you have from A through D. So, again, if all of you could try to participate, what's your next step in this 48-year-old patient? You want to go directly to an antireflux procedure or antireflux surgery? You want to do a 96R wireless pH study of medications? Do you want to do a pH impedance on medical therapy or you want to stop all medical therapy and repeat an endoscopy to exclude eosinophilic esophagitis? So again, a very practical sort of a question, I think we see this quite frequently in practice. So let's have you start voting on A, B, C, or D. So unfortunately, we won't have any music while we are doing this. So no Jeopardy-style music right now, but we'll see what your responses are. And then of course, we'll go back to our expert panel and get them to also tell us what they would think is the right answer. So John and Mimi, there appears to be a little bit of a tie here between whether we want to do a pH study off of medication or do a pH impedance on PPI therapy. And I think it's a good discussion that we'll have. So let's go on to our next question. Okay, so this is question number two. And again, thank you all for voting and to see that you're all not just muted but listening to the presentation. So 36-year-old patient with dysphagia to solids and liquids. Hyperendoscopy with biopsy is normal, so we pretty much ruled out eosinophilic esophagitis. HRM is done, which shows a small hiatus hernia, an IRP of 4.6, a DCI of 30,000, a distal latency of five seconds, and 100% peristalsis. So again, you look at the HRM findings, and John very nicely went through a number of these examples. So what's your diagnosis based on these findings? A, achalasia. B, EG junction outflow obstruction. C is esophageal spasm. 4, or D, is hypercontractile esophagus. And E is ineffective esophageal mortality. So again, A through E, look at those responses, and let's have you vote on this. And again, we'll go through the same during the entire day, just to get you guys involved as well as help some of these questions be resolved by our experts who will be doing it. So OK, so let's look at the responses. The majority went for hypercontractile esophagus, John, with then next one was esophageal spasm by 16%. So OK, thank you all for voting. Now we'll get to our Q&A session. Mimi, you're on. John, you're on as well. Mohan has been sending some requests to all the participants. So Mimi, starting off with you, and again, you highlighted nicely that there are different ways of doing it. We obviously do the pH placement a little bit different than you showed us. So the question is, do you always need endoscopy to place a capsule for pH monitoring? No, you actually can do it, I believe, transnasally. We've never done it that way. It's certainly something that is patient preference. Most of our patients, when we discuss the pros and cons of either technique, prefer not to have the least traumatic or the most painful potentially perceived way. So a lot of people opt for sedated endoscopy. John, any differences in your practice? I mean, how do you do it? I know you probably are following the wrong Hopkins methodology, but have you changed in Stanford? Yeah, I mean, mine's somewhat different a little bit in that I do about 50% of my cases with conscious sedation. And so it's often very challenging to keep the scope in with the wireless probe and at the same time. And by the time that we're placing, it's towards the end of the case and patients are starting to wake up. And I've done, since coming to Stanford, I just looked it up, I've done 401 placements coming here. So I've done enough where I kind of can feel it going past the UES. And so I'm often taking the scope out, placing the wireless probe, and doing it by feel, which is not what I would recommend for everyone. But I feel like I've done enough that I get the sense of when it's passing. And my overall detachment rate has been less than 1%. John, a couple of questions from the Q&A box. For the DCI, do you need one swallow more than 8,000 to diagnose jackhammer or two or more? So it's 20% or more. And so most times it's 10 swallows. So it translates if you have two or more, that works. And the second question is, how important it is in jackhammer to know if the LES is involved or not? The questions where, do you do a time-variant esophagram, do you do endoflip? Because if we're going to do POEM, does that change treatment? Can you answer briefly, please? Yep. So basically, when you're hammered, everything's a nail. So almost everyone in my practice gets flipped if they have this. And I'm going and measuring it directly. Because POEM is so invasive and jackhammer is of unclear significance clinically, I think it is important to do something to look at the outflow, whether that be a time-variant or else flip. OK. So going back, John, to the first case that you had, would you agree with the audience about doing the 96 RPH monitoring in that situation? Yes, I would. Yeah. You know, I tried to make that a little challenging with the small hernia and the LAA. But this goes back towards Leon consensus, which Mimi had talked about prior. And the thought with that, the take-home with testing is that if you're 100% sure it's GERD, then you can test on a MedStem. If you're not 100% sure it's GERD, then testing off is better. And LAA is subjective enough that the fact that there's not any real symptom improvement with acid suppressive therapy at all, I personally feel a little more comfortable testing it. Yeah. And John, thanks for emphasizing LA grade A. I mean, and just again, for the attendees, I mean, the Leon consensus pretty much ruled out saying that if there was LA grade A, it is probably not a very reliable marker for reflux disease. And again, last thing, John, is John Dewitt from Indiana would like to know, do you diagnose hypercontractile esophagus just based on one DCI, which is greater than 8,000, or do you require more than one? Yeah, it's got to be two or more. That's if you have 10 swallows. If you've done like 15 swallows, it's got to be three or more, but in theory, 20% or more. The first Chicago classification had just said if you had one, one or more, which was high, and they subsequently changed that because there are people who are normal who may have one rare hypercontractile swallow, so it's got to be at least 20 or more. John, there are some questions about treatment, role of pneumatic dilation and POEM in different types of achalasia and jackhammer. So I mean, my sense looking at the literature is that if you have type 3 achalasia, I think POEM is better because it lets you attack the body, which you can't get from the dilation. If you have type 1 achalasia and you don't have any real pressurization in the esophagus, then the more effective the outlet release, the better patients do. So whether that be Heller or POEM is probably dealer's choice, but that's probably more effective than balloon. For type 2, though, they still will generate pressure in the esophagus, and these patients actually do pretty well with going in and doing balloon as well. So I think that is something that's an option. There are prognostic factors as to who's more likely to get benefit from a balloon. So if you're past the age of 40, if you're a woman, if you've had partial response towards going and stretching towards 20, you might be more inclined in that situation. In my practice, I now do about 15 pneumatic a year, so I'm not doing tons, and I'll say that most of those patients are actually people who have had prior Heller's or POEM, and then I'm going back and fine-tuning. Mimi, for 48 versus 96 RPH monitoring, I mean, again, and I think thanks for all the questions John and team were putting there on. I mean, it's a practical issue. I mean, in our practice, we are still doing 48 hours, so are we doing it wrong, Mimi, or is that a reasonable thing to be doing about? And the question is, you know, what's the difference in the yield between 48 versus 96 cost reimbursement? That was the question again. Yeah, no, so you're never wrong. You know that fatigue, but certainly you could, it depends on the practice. We're fortunate we have a lot of recorders, so having it out for that long and having the patients return, so availability is certainly an issue for your practice. We did a study, it's not published, but we have a lot of data, and there's actually a couple other studies that show the increased diagnostic yield and sensitivity of extending it to 96 hours. In our data, day three was actually had the highest additional yield for the BRAVO pH monitoring test, so we've routinely gone to 96 hours, and so we just have a lot of BRAVO recorders, and we're really fortunate for that. In terms of cost of reimbursement, I don't really know. John, you may know if there's any difference. I don't think there is as far as I know. The practicality is that often the patients, when they, you know, basically want to capture their normal, you know, their normal, right? So, you know, GERD is sometimes, it's variable, like high blood pressure, diabetes, sugar, you know, so at least in theory, if you have greater sampling time, and again, you know, we do look at the average time over four days, but there is data that shows that even the highest one day, you know, as exposure time can really be improving significantly the sensitivity, so it really depends on your question. I want to just address that one thing about the first case, if I may. So you could argue, we see a lot of these patients in our heartburn center, right, refractory heartburn, do they have GERD or not, or functional, and, you know, if you've, depending if you've seen the patients really refractory, and there's some hint that maybe there's esophagitis, even though it's not considered real esophagitis, that if they're going to be potentially heading to surgery, we might consider the pH impedance on meds, and just because you can look at total reflux events, and you want to get the manometry anyway, just because if they may be surgical candidates, and that's the way the management's going to go, you already have that, you know, done. So that's just one other way to approach it.

refractory heartburn

pH study off medication

pH impedance on medication

achalasia

jackhammer esophagus