1. Demonstrate Real-Time HRM Pattern Recognition Intubation Folded Catheter

2. Intubation via HRM

3. Folded Catheter via HRM

4. What is Impedance and what does it add to manometry and pH testing? Impedance is the measureable amount of change in the electrical signal of any specific substance. Esophageal and/or pH impedance is the measureable amount of change in the electrical signal of a specific swallowed substance as it passes over a sensor that is designed to measure impedance. • Demystifying Impedance • Esophageal motility and/or impedance does two things: • Detects the presence of liquid and air. • Determines the direction of its movement and how long it stays there.

5. Combining real-time Bolus Transit & Muscle Function: Visualize the liquid bolus as it is moved from the pharynx to the stomach by the pressure gradients created during swallows Pharynx-to-stomach high-resolution pressure profile Pharynx-to-stomach high-resolution liquid bolus transit profile

6. THE LIVING ESOPHAGUS ™ The Combined Uninterrupted Visualization of the Real-Time Pressures & Resulting Bolus Transit of the Entire Swallowing Anatomy

7. Normal Swallow Physiology :Liquid Bolus (Gray) is stripped proximal-to-distal by uninterrupted Pressure Wave (Red) PressureImpedance UES relaxes, bolus quickly fills esophagus UES contracted, Striated muscle wave in progress, proximal bolus stripped Wave in striated/smooth transition zone, little bolus movement Distal smooth muscle wave in progress, bolus largely cleared Wave reaches level of LES, Bolus cleared

8. High-Resolution Impedance Data Captured: (Normal Swallow)Measurement of Full-Anatomy Pressures plus the Flow of Swallowed Liquid (1) 36 fully-circumferential sensors and 18 fully-circumferential impedance liquid sensors simultaneously span the entire swallowing anatomy in only one catheter position for the 10-minute study. Easily visualize (2) UES relaxation and (3) UES closure during the swallow, as well as the (4) full-anatomy pressures (low-pressure blue to high-pressure red) moving from pharynx to stomach. Easily visualize the (5) swallowed liquid (magenta) being driven downward by these uninterrupted swallowing pressures, through the (6) LES as it relaxes, with the liquid fully clearing into the stomach after (7) LES closure. 2 3 Hot/High Pressure 1 4 4 Cold/Low Pressure 5 5 7 6

9. The Chicago Classifications of Normal & Abnormal Swallows Using Esophageal Pressure Topography

10. The Chicago Classifications of Motility Disorders Using Esophageal Pressure Topography

11. Comparing Conventional Manometry and High-Resolution Impedance Manometry: Can Both Methods Accurately Diagnose Motility Disorders? A REVIEW OF THREE DISORDERS: • Ineffective Esophageal Body Pressures w/Retrograde Distal Spasm & Retrograde Bolus Escape (Reflux) • Achalasia • Hiatal Hernia

12. Conventional Manometry Data Captured: (Unable to detect Ineffective Peristalsis with Bolus Entrapment)Cannot Detect Ineffective Upper Esophageal Pressures and Lack of Swallow TransitIn this patient, since the sensors do not span the entire swallowing anatomy, the (1) upper esophagus swallowing pressures appear normal. It is therefore assumed that swallowed liquids are being effectively transported downward toward the stomach. However, the next slide of this same patient studied with high-resolution impedance manometry reveals why this assumption is incorrect. 1

13. High-Resolution Impedance Data Captured: (Accurately Detects Ineffective Peristalsis with Bolus Entrapment)Reveals Ineffective Upper Esophageal Pressures and Ineffective Swallow TransitIn this same patient, (1) there is a 7-cm interruption in upper esophagus swallowing pressures (low-pressure blue to high-pressure red), resulting in (2) swallowed liquid (magenta) entrapment. (3) The lower esophagus then actually pressurizes backwards, causing the trapped liquid to then (4) reflux backwards toward the mouth. This patient’s accurate diagnosis is non-peristaltic long upper esophageal transition zone with retrograde spastic peristalsis and reflux. 4 4 1 2 3 3

14. The Anatomy of Achalasia

15. Classic Achalasia “Bird’s Beak” and Dilated Distal Esophagus via Barium Swallow

16. The Stages of Untreated Achalasia B: 2 years untreated A: Early Achalasia GI Motility online (May 2006) | doi:10.1038/gimo53 C: End stage Achalasia with Megaesophagus

17. Conventional Manometry Data Captured: (Achalasia)Cannot Detect Movement of Lower Sphincter or Transit of Swallowed LiquidIn this patient, the (1) lower esophageal sphincter shows a drop in pressure during swallows. It is therefore assumed that the sphincter is relaxing, allowing swallowed liquids to transport effectively through the sphincter and into the stomach. However, the next slide of this same patient studied with high-resolution impedance manometry reveals how this assumption is incorrect. 1

18. High-Resolution Pressure Data Captured: (Achalasia)Detects Movement of Lower Sphincter and Ineffective Transit of Swallowed LiquidIn this patient, the sensors that span the entire anatomy easily reveal that the (1) lower esophageal sphincter actually moves upward during esophageal shortening, and (2) does not relax (note the non-relaxing LES pressure remains hypertensive at 73 mm Hg). The next slide (with the impedance data displayed) reveals the resulting complete lack of bolus transit. 2 1

19. High-Resolution Impedance Data Captured: (Achalasia)Reveals the Resulting Ineffective Transit of Swallowed LiquidAs a result of the non-relaxing lower esophageal sphincter, the (1) tight sphincter (Bird’s Beak) prevents swallowed liquids (magenta) from transporting effectively through the sphincter and into the stomach. There is a (2) complete lack of any esophageal swallowing pressures (blue to red), which further results in a (3) complete entrapment of swallowed liquid (magenta). This, in combination with the non-relaxing lower sphincter yields an accurate diagnosis of Classic Achalasia (Type II). 2 3 3 1 1

20. Hiatal Hernia

21. Conventional Manometry Data Captured: (Hiatal Hernia)Nearly Impossible to Detect Hiatal Hernia In this patient, the swallow looks normal. And due to the limited number of pressure sensors, there is no observable hiatal hernia, which occurs when there is a hole in the diaphragm and a portion of the stomach herniates upward into the chest cavity, with a resulting separation of the lower esophageal sphincter from the diaphragm. However, the next slide of this same patient studied with high-resolution manometry reveals the obvious presence of a hiatal hernia, and the resulting pressures that are the cause of this patient’s previously-diagnosed reflux.

22. High-Resolution Impedance Data Captured: (Hiatal Hernia)Easy to Detect Hiatal HerniaAs a result of sensors that span the entire swallowing anatomy, a (1) 4.2 cm hernia sac (light blue span) is easily seen with a separation between the (2) lower sphincter and the (3) diaphragm. This patient refluxes because the (4) diaphragm pinch pressure during inspiration is 19 mmHg and causes retrograde movement of sac contents across the (5) hypotensive LES barrier pressure of only 3 mmHg. 2 5 1 3 4