Manometry In Clinical Practice Research Articles

High-resolution esophageal manometry in clinical practice – An Indian perspective

High-resolution esophageal manometry (HREM) is a technique to determine the function of esophageal musculature and the integrity of the lower esophageal sphincter. This test is commonly used for evaluation of nonobstructive dysphagia, assessment of peristaltic reserve before anti-reflux surgery, symptoms of regurgitation, and noncardiac chest pain unexplained by endoscopic evaluation. The current review deals with the spectrum of esophageal motility disorders in India and reviews the technique and reporting of HREM. The clinical utility of HREM in Indian setting with special reference to challenges faced has been discussed in detail.

The role of ambulatory 24-hour esophageal manometry in clinical practice.

High‐resolution manometry revolutionized the assessment of esophageal motility disorders and upgraded the classification through the Chicago Classification. A known disadvantage of standard HRM, however, is the inability to record esophageal motility function for an extended time interval; therefore, it represents only a more snapshot view of esophageal motor function. In contrast, ambulatory esophageal manometry measures esophageal motility over a prolonged period and detects motor activity during the entire circadian cycle. Furthermore, ambulatory manometry has the ability to measure temporal correlations between symptoms and motor events. This article aimed to review the clinical implications of ambulatory esophageal manometry for various symptoms, covering literature on the manometry catheter, interpretation of findings, and relevance in clinical practice specific to the evaluation of non‐cardiac chest pain, chronic cough, and rumination syndrome.

Utility of Esophageal High-Resolution Manometry in Clinical Practice: First, Do HRM.

Esophageal high-resolution manometry (HRM) has advanced the understanding of esophageal motor function and the ability to diagnose and manage disorders of esophageal motility. In this review, we describe the indications for and the technical performance of HRM. The Chicago classification of esophageal motor function, now in its third iteration, streamlines and standardizes the nomenclature and basic interpretation of HRM data depicted as Clouse topographic plots. In clinical practice, HRM is an important diagnostic test for patients with dysphagia as well as patients with suspected gastroesophageal reflux disease (GERD), particularly in those patients with a suboptimal symptomatic response to antisecretory therapy. HRM can support diagnoses such as achalasia, as well as provide evidence for behavioral disorders such as rumination syndrome or supragastric belching with the assistance of postprandial HRM with impedance. Further, the GERD classification of motor function introduces a three-part hierarchical evaluation of esophageal motor function in GERD, highlighting the value of assessment of esophageal contractile reserve through provocative maneuvers during HRM such as multiple rapid swallows.

High resolution manometry and new classification of esophageal motility disorders.

To present application of Chicago classification criteria of esophageal motility disorders defined in high resolution manometry in clinical practice. High-resolution manometry is the most exact hi-tech diagnostic method for esophageal motor function disorders according to Chicago classification v3.0. Uniqueness of the method consists in capacity to define integrated quantitative and qualitative metrics of esophageal contractile function and to establish their specific disorders e.g.: change of intrabolus pressure at disorders of esophagogastric junction (EGj) outflow, hypercontractile esophagus, fragmented contractions and weak or failed peristalsis, distal esophageal spasm. Assessment of the type of achalasia subtypes has significant impact on the patients' treatment choice. According to anatomical location of the lower esophageal sphincter and crural diaphragm several morphological types of gastro-esophageal junction are defined that determine severity of gastroesophageal reflux disease. Multiple rapid swallow responses during esophageal high-resolution manometry reflect esophageal body peristaltic reserve and is a predictor of postoperative complications. Differential diagnosis of belching type became possible at combined application of high-resolution manometry and impedance measurement. High-resolution manometry is a fundamental diagnostic test of esophageal motor function disorders. Clinical application of this method significantly expands diagnostic potential and allows to carry out personalized treatment that increases treatment quality.

Practice guidelines on the use of esophageal manometry – A GISMAD-SIGE-AIGO medical position statement

Patients with esophageal symptoms potentially associated to esophageal motor disorders such as dysphagia, chest pain, heartburn and regurgitation, represent one of the most frequent reasons for referral to gastroenterological evaluation. The utility of esophageal manometry in clinical practice is: (1) to accurately define esophageal motor function, (2) to identify abnormal motor function, and (3) to establish a treatment plan based on motor abnormalities. With this in mind, in the last decade, investigations and technical advances, with the introduction of high-resolution esophageal manometry, have enhanced our understanding and management of esophageal motility disorders. The following recommendations were developed to assist physicians in the appropriate use of esophageal manometry in modern patient care. They were discussed and approved after a comprehensive review of the medical literature pertaining to manometric techniques and their recent application. This position statement created under the auspices of the Gruppo Italiano di Studio per la Motilità dell’Apparato Digerente (GISMAD), Società Italiana di Gastroenterologia ed Endoscopia Digestiva (SIGE) and Associazione Italiana Gastroenterologi ed Endoscopisti Digestivi Ospedalieri (AIGO) is intended to help clinicians in applying manometric studies in the most fruitful manner within the context of their patients with esophageal symptoms.

Role of Anorectal Manometry in Clinical Practice.

Physiologic assessment of the anorectum and pelvic floor by anorectal manometry and balloon expulsion testing provides important insights into the pathologic processes underlying defecatory disorders and guides treatment, specifically the use of biofeedback for the treatment of dyssynergic defecation and the identification of possible structural abnormalities of the pelvic floor. While symptoms and digital rectal examination may suggest pelvic floor dysfunction to the clinician, only pelvic floor testing provides definitive diagnoses of these often treatable abnormalities. The use of anorectal manometry in clinical practice is currently limited by substantial variation in performance of the test and interpretation of the results, but anorectal manometry with the addition of balloon expulsion test to improve specificity provides the best current modality for the diagnosis of dyssynergic defecation. With the introduction of high-resolution and three-dimensional, high-definition probes, our ability to characterize the structure and function of the anorectum has never been better, though further research is still needed to improve our ability to diagnose pelvic floor dysfunction and refer appropriate patients to treatment. In areas where the availability of anorectal manometry (ARM) is limited, a thorough digital rectal exam performed by an experienced clinician plus the balloon expulsion test alone may identify appropriate patients to refer for additional testing. This review describes the appropriate indications for and appropriate performance of anorectal manometry in clinical practice with an eye toward the diagnosis of dyssynergic defecation in patients with chronic constipation, fecal incontinence, and chronic proctalgia.

How to Perform and Interpret Upper Esophageal Sphincter Manometry

Manometry of the pharynx and the upper esophageal sphincter (UES) provides important information on the swallowing mechanism, especially about details on the pharyngeal contraction and relaxation of the UES. However, UES manometry is challenging because of the radial asymmetry of the sphincter, and upward movement of the UES during swallowing. In addition, the rapidity of contraction of the pharyngoesophageal segment requires high frequency recording for capturing these changes in pressure; this is best done with the use of solid state transducers and high-resolution manometry. UES manometry is not required for routine patient care, when esophageal manometry is being performed. The major usefulness of UES manometry in clinical practice is in the evaluation of patients with oropharyngeal dysphagia.

High‐resolution manometry in clinical practice: utilizing pressure topography to classify oesophageal motility abnormalities

High-resolution manometry capable of pressure monitoring from the pharynx to the stomach together with pressure topography plotting represents an unquestionable evolution in oesophageal manometry. However, with this advanced technology come challenges and one of those is devising the optimal scheme to apply high-resolution oesophageal pressure topography (HROPT) to the clinical evaluation of patients. The first iteration of the Chicago classification was based on a systematic analysis of motility patterns in 75 control subjects and 400 consecutive patients. This review summarizes the analysis process as it has evolved. Individual swallows are analysed in a stepwise fashion for the morphology of the oesophagogastric junction (OGJ), the extent of OGJ relaxation, the propagation velocity of peristalsis, the vigour of the peristaltic contraction, and abnormalities of intrabolus pressure utilizing metrics that have now been customized to HROPT. These results are then synthesized into a comprehensive diagnosis that, although based on conventional manometry criteria, is also customized to HROPT measures. The resultant classification objectifies the identification of three unique subtypes of achalasia. Additionally, it provides enhanced detail in the description of distal oesophageal spasm, nutcracker oesophagus subtypes, and OGJ obstruction. It is our expectation that modification of this classification scheme will continue to occur and this should further clarify the utility of pressure topography plotting in assessing oesophageal motility disorders.

Discriminative Value of Anorectal Manometry in Clinical Practice

Guidelines recommend anorectal manometry in patients with fecal incontinence and chronic constipation. However, limited evidence supports the utility of manometric testing. We retrospectively reviewed tracings obtained between November 2005 and May 2008. A total of 298 patients (86% women; average age 52 years) were included. The main indications were incontinence (51%) and constipation (42%). Patients suffering from incontinence were older and had lower resting and squeeze pressure compared to continent patients. However, the discriminative power of manometric pressure data was poor, with low sensitivity and specificity. An abnormal straining pattern suggesting dyssynergic defecation was seen in 43% of constipated patients compared to 13% of patients with fecal incontinence. A concordance between manometric patterns and the balloon expulsion test was seen in 72%. The low sensitivity and specificity of manometric parameters does not support the routine use of anorectal manometry in patients with defecation disorders.

Clinical Utility of Selective Esophageal Manometry in a Tertiary Care Setting

To evaluate the utility of selective esophageal manometry in clinical practice. Retrospective data from 200 subjects was reviewed. Manometry was considered to be (1) high clinical utility when specific abnormality was identified resulting in therapeutic intervention, (2) low clinical utility when specific abnormality was identified without alteration of therapy, (3) limited clinical utility when manometry was normal. High, low, and limited clinical utility was noted in 47, 40, and 13% of instances. Manometry was of high utility in patients with dysphagia or non-cardiac chest pain (P < 0.05), and low utility in gastroesophageal reflux (P < 0.05). (1) Esophageal manometry has high clinical utility in dysphagia after exclusion of structural disorders; and non-cardiac chest pain after careful exclusion of reflux. (2) Ineffective motility disorder has high association with gastroesophageal reflux disease but low clinical utility except in preoperative assessment for fundoplication. (3) Esophageal manometry is of high utility in clinical practice when used in conjunction with other diagnostic exclusions.

AGA technical review on the clinical use of esophageal manometry

AGA technical review on the clinical use of esophageal manometry

Role of stationary esophageal manometry in clinical practice: Manometric results in patients with gastroesophageal reflux, dysphagia or non-cardiac chest pain

The present study was carried out to evaluate the diagnostic usefulness of stationary esophageal manometry in 263 patients divided into three groups: 150 patients with reflux symptoms, 68 with dysphagia, and 45 with non-cardiac chest pain. Patients with endoscopic abnormalities were excluded. Standard manometry was performed following the station pull-through technique. In the group of patients with reflux symptoms 40.7% had a normal manometry and 57.3% had abnormalities, being the most frequent (43%) hypotensive lower esophageal sphincter. In the dysphagia group, 20.6% of manometries were normal and 79.4% were abnormal, of which achalasia was the most frequent disorder (53.7%). In the case of non-cardiac chest pain, 42.2% of patients had a normal manometry and 57.8% an abnormal one, of which hypotensive lower esophageal sphincter was the most frequent abnormality. A significant higher proportion of manometric alterations were found in the dysphagia group compared to reflux symptoms and non-cardiac chest pain (p < 0.05). No statistical differences were found between the reflux and the non-cardiac chest pain groups. Manometry yields a higher diagnostic value in patients with dysphagia, and therefore manometry should be performed routinely after the exclusion of any organic esophageal disease. Manometry is not a first-choice functional diagnostic test in the study of patirnts with gastroesophageal reflux or non-cardiac chest pain.

Role of oesophageal manometry in clinical practice.

The present study evaluates the role of oesophageal manometry in clinical practice. Over 5 years, 347 consecutive patients were evaluated in our oesophageal laboratory. The reasons for referral were: dysphagia (11.5%), gastro-oesophageal reflux disease (GORD) (46.7%), non-cardiac chest pain (28.5%), connective tissue disease (6.9%) and other symptomatology (6.3%). Patients were classified into the following five groups according to the referral diagnosis: dysphagia (40 patients), gastro-oesophageal reflux disease (GORD) (162 patients), non-cardiac chest pain (99 patients), connective tissue disease (24 patients) and other symptomatology (22 patients). Abnormalities in oesophageal motility were detected in 90% of patients with dysphagia, in 40.1% of patients with GORD, in 47.5% of subjects with non-cardiac chest pain, in 45.8% of patients with connective tissue disease and in 18.2% of subjects with other symptomatology. The high prevalence of abnormalities in the dysphagia group was statistically significant (p < 0.001), and the range of 95% confidence intervals (0.81-0.99) suggests that the value found may be a reasonably good estimate of percentage of anomalies detectable in the dysphagia patient population. In the dysphagia group, the initial diagnosis was confirmed in 40% of patients and changed in 52.5%; in only 7.5% of cases were the manometry results not relevant for determining an appropriate diagnosis. Manometry substantially contributed to patients receiving the correct treatment in 82.5% of cases (p < 0.001 among all groups). In the GORD group and in the non-cardiac chest pain group, the results of manometry were not relevant for confirming or changing a diagnosis in 59.8% and 53.5% of cases respectively; nevertheless, in both groups, on the basis of manometry results, the treatment was changed in 42.5% of patients (p < 0.01 vs. other symptomatology group). In conclusion, on the basis of the present data, we can emphasize the usefulness of oesophageal manometry assessment in patients with dysphagia or non-cardiac chest pain, with negative routine examinations, and also in patients with refractory GORD who have been considered for antireflux surgery.

The changing use of esophageal manometry in clinical practice

Objective: Clinical practice guidelines now advise against the use of esophageal manometry in the early evaluation of unexplained chest pain. We examined data from patients referred for manometric evaluation over a 10-yr period (1987–1996) to see if clinicians were changing practice patterns and whether manometric diagnoses were affected by the changes. Methods: Principal indications for the procedure and manometric findings were extracted from a review of 1162 subjects referred to a single clinical laboratory. The tracings were analyzed using a standardized classification method and categorized according to a pathophysiology-based scheme. Referral indications and manometric diagnoses were compared for the first and second 5-yr periods of study. Results: Chest pain as a referral indication declined from the first to the second half of the study period (odds ratio, 0.44; p < 0.0001), whereas dysphagia and preoperative evaluations became more common (odds ratio, 1.3; p < 0.05; odds ratio, 13.7; p < 0.0001, respectively). Similarly, hypermotility disorders decreased in frequency (odds ratio, 0.63; p = 0.0001), whereas hypomotility disorders increased (odds ratio, 1.6; p < 0.01). The decrease in hypermotility disorders was solely related to a decrease in nonspecific spastic disorders, including nutcracker esophagus (odds ratio, 0.58; p < 0.0001); the proportion of diagnoses of achalasia and diffuse esophageal spasm remained stable. Conclusions: These data show that practice patterns are already following current guidelines. They also reflect the disillusionment of clinicians with the poor specificity of manometry in chest pain management, the increasing popularity of antireflux surgery, yet the ongoing observation that nonspecific spastic disorders are closely associated with unexplained chest pain and may have a still-undefined pathogenetic role.

The changing use of esophageal manometry in clinical practice.

Clinical practice guidelines now advise against the use of esophageal manometry in the early evaluation of unexplained chest pain. We examined data from patients referred for manometric evaluation over a 10-yr period (1987-1996) to see if clinicians were changing practice patterns and whether manometric diagnoses were affected by the changes. Principal indications for the procedure and manometric findings were extracted from a review of 1162 subjects referred to a single clinical laboratory. The tracings were analyzed using a standardized classification method and categorized according to a pathophysiology-based scheme. Referral indications and manometric diagnoses were compared for the first and second 5-yr periods of study. Chest pain as a referral indication declined from the first to the second half of the study period (odds ratio, 0.44; p < 0.0001), whereas dysphagia and preoperative evaluations became more common (odds ratio, 1.3; p < 0.05; odds ratio, 13.7; p < 0.0001, respectively). Similarly, hypermotility disorders decreased in frequency (odds ratio, 0.63; p = 0.0001), whereas hypomotility disorders increased (odds ratio, 1.6; p < 0.01). The decrease in hypermotility disorders was solely related to a decrease in nonspecific spastic disorders, including nutcracker esophagus (odds ratio, 0.58; p < 0.0001); the proportion of diagnoses of achalasia and diffuse esophageal spasm remained stable. These data show that practice patterns are already following current guidelines. They also reflect the disillusionment of clinicians with the poor specificity of manometry in chest pain management, the increasing popularity of antireflux surgery, yet the ongoing observation that nonspecific spastic disorders are closely associated with unexplained chest pain and may have a still-undefined pathogenetic role.

Audit of the role of oesophageal manometry in clinical practice.

This oesophageal laboratory serves a population of 1.5 million. The study aimed to review referral patterns and assess the cost effectiveness of oesophageal manometry in clinical practice. All 276 consecutive manometry studies performed between 1988 and 1991 were reviewed. Reasons for referral in the 268 first referrals were: dysphagia 50.4%, non-cardiac chest pain 23.1%, gastro-oesophageal reflux disease 14.2%, connective tissue disease 11.2%, and 'other' 1.1%. Manometry was normal in 49.3%, showed achalasia in 17.9%, diffuse oesophageal spasm in 13.4%, connective tissue disease in 7.8%, hypertensive lower oesophageal sphincter in 4.5%, nutcracker oesophagus in 2.6%, and 'other' in 4.5%. A positive diagnosis was significantly more common if dysphagia was the reason for referral (65.9% v 35.3%, p < 0.01). A positive diagnosis was established in 60% of patients referred with connective tissue disease, 30.6% with non-cardiac chest pain, and 21.1% with gastro-oesophageal reflux disease. A positive diagnosis was significantly more common in connective tissue disease when symptoms were present (85% v 10%, p < 0.05). Management was changed in 48.9% of all patients because of manometry findings. The cost of each oesophageal manometry study was calculated to be 63.00 pounds: every change in patient management cost 129.00 pounds. In conclusion, oesophageal manometry changed management in over 20% of patients with non-cardiac chest pain or gastro-oesophageal reflux disease and in over 60% of those with dysphagia. It is, therefore, a useful and cost effective test in patients with these symptoms.