Prospective serial diagnostic study: the effects of position and provocative tests on the diagnosis of oesophageal motility disorders by high-resolution manometry.

Abstract

Standard high-resolution manometry (HRM) protocols are based on 10single water swallows acquired in the supine position. To assess the impact of position, rapid drink challenge and solid test meal on the diagnosis of oesophageal motility disorders. Seventy-two healthy volunteers (20-76years) and 366 consecutive patients (18-90years) completed HRM with 10 single water swallows in the supine and upright positions. Rapid drink challenge was performed twice, before and after the solid test meal. Diagnosis based on single water swallows in the supine position (Chicago Classification v3.0) was compared with results in the upright position and with provocative tests. Overall, diagnostic agreement in the supine and upright positions was present in 296/438 (67.6%) subjects. This increased to 90.0% when ineffective oesophageal motility was considered with normal motility. Integrated relaxation pressure was 4mm Hg higher in the supine position. There was a higher prevalence of inconsistent, likelyfalse positive, diagnoses of outlet obstruction in the supine compared to the upright position (16/20 vs 1/4 patients, P=0.0007). Similarly,the difference in concordance for thediagnosis of oesophago-gastric junction obstruction or achalasiabetween single water swallows in the supine and upright positions with solid test meal was significant (12/29 (41.4%) vs 12/14 (85.7%), P=0.0087). Diagnostic agreement for oesophageal motility disorders based on single water swallows in the upright and supine positions was moderate, with frequent discordant findings for ineffective motility and outlet obstruction. HRM studies can be performed in either position, using appropriate reference values. Rapid drink challenge or solid test meal can resolve diagnostic discrepancies.