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• W2914186217 abstract "PIP is produced by diaphragmatic moverment during respiration. In conventional manometry, it was used as a landmark to locate the approximate location of the LES. However, using this landmark in small hiatal hernia (HH) can give inaccurate LES location. The role of PIP in the era of high resolution manometry (HRM) has diminished. This is especially due to the easy recognition of HH using its colored pressure topography. HH is identified by 2 distal high pressure zones with the peristaltic sequence ending at the level of the LES, distinguishing it from the diaphragmatic pressure zone. Here we present a case of 72 year old female, referred to our motility laboratory by her primary care physician. Her main complain is recurrent episodes of epigastric pain, associated with nausea, dizziness and shortness of breath. Her past medical history includes hypertension and GERD. She denied dysphagia, weight loss and any atypical GERD symptoms. The patient states she had similar attacks throughout the last 8 years. Her work up included HRM and stress perfusion cardiac MRI. The HRM showed normal peristalsis with normal LES metrics (resting pressure and integrated relaxation pressure were 19 and 14 mm/Hg respectively). The only interesting finding was the absence of detectable PIP (figure 1). The stress perfusion MRI showed no cardiac perfusion and left ventricular function pararmeters. Incidentally, the MRI showed complete intrathoracic positioning of the stomach. CT abdomin was performed and it confirmed the finding (figure 2).Figure: HRM of the case. There was absence of detectable PIP with same respiratory cyclic color fluctuation above and below the LES.Figure: A: MRI showing the presence of intrathoracic stomach, B: CT abdomen confirming the same finding.Figure: An example of normal manometry with detectable PIP at the level of the LES. The respiratory cyclic color fluctuation is inverted in the region below the LES.Discussion: Locating the PIP is relatively easy using HRM. However, one must learn to recognize the color contour appearance of this phenomenon. In addition, its presence /absence can be roughly deetermined by observing the respiratory variations in the HRM color plot. The typical blue of the intraesophageal pressure darkens with inspiration and lightens with expiration. This finding assists in locating the diaphragm and so the PIP, since intraabdominal pressure changes inversely to the intrathoracic pressure with respiration (figure 3). In our case, these respiratory cyclic pressure fluctuations were the same above and below the LES. Lessons learned: Locating the PIP is important, despite not being used in the HRM algorithm of the Chicago classification. As shown in this case, the absence of detectable PIP reflects a significant structural pathology (complete intrathoracic stomach)." @default.
• W2914186217 created "2019-02-21" @default.
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• W2914186217 date "2017-10-01" @default.
• W2914186217 modified "2023-09-26" @default.
• W2914186217 title "The Pressure Inversion Point (PIP): Passeʼ or Paramount" @default.
• W2914186217 doi "https://doi.org/10.14309/00000434-201710001-01668" @default.
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