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Esophageal Manometry

  • Author: Philip O Katz, MD, FACP, FACG; Chief Editor: Kurt E Roberts, MD  more...
 
Updated: Nov 14, 2014
 

Overview

Background

Esophageal manometry measures the different factors that play a role in the motility and function of the upper esophageal sphincter, the body of the esophagus, and the lower esophageal sphincter.[1, 2]

The esophagus can be affected by a variety of disorders that may be intrinsic or secondary to another pathologic process, but the resulting symptoms are usually not pathognomonic for a specific problem, making diagnosis somewhat challenging. Although detailed history taking, review of symptoms, and physical examination can orient the clinician in the right direction, further tests, including esophageal manometry, are sometimes necessary for establishing a diagnosis. The first attempts to test esophageal function date back to 1883,[3, 4] but it was not until the 1970s when the technology was developed that would allow a proper recording of esophageal pressure dynamics.

Indications

Esophageal manometry is indicated for the following situations:

  • Evaluation of noncardiac chest pain or esophageal symptoms not diagnosed by endoscopy (or after gastroesophageal reflux disease [GERD] has been excluded)
  • Evaluation for achalasia or another type of nonobstructive dysphagia
  • Preoperative evaluation for patients undergoing corrective surgery for gastroesophageal reflux disease, particularly if an alternative diagnosis like scleroderma or achalasia is being considered
  • Postoperative evaluation of dysphagia in patients who underwent corrective surgery for reflux or after treatment of achalasia
  • Prior to esophageal pH monitoring to assess the location of the lower esophageal sphincter for proper electrode positioning
  • Evaluation of esophageal motility problems associated with systemic diseases

Contraindications

Esophageal manometry is contraindicated in the following situations:

  • Patients with altered mental status or obtundation
  • Patients who cannot understand or follow instructions
  • Suspicion or known pharyngeal or upper esophageal obstruction (eg, tumors)
  • Patients with severe clotting disorders
  • Patients with known esophageal problems such as deep ulcers, varices, Zenker's diverticula, and strictures

Technical Considerations

Procedure Planning

Some conditions can lead to technical difficulties when performing esophageal manometry, such as achalasia, large hiatal hernias, intrathoracic stomach, and patients with prior esophageal surgery, among others. Knowledge about these conditions can help the technician prepare beforehand for difficulties that may arise. A variety of problems can affect the esophagus and produce multiple symptoms; this can give some insight into what the diagnosis may be and how to tailor the procedure to the suspected affected area.

Complication Prevention

If problems or resistance that is unable to be overcome with reasonable pressure is encountered when trying to pass the manometry catheter through the nostrils (particularly in patients with prior nasal surgery, deformation, or small nares), it can instead be introduced through the mouth. This will avoid lesions caused by forcing the catheter against resistance.

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Periprocedural Care

Patient Education & Consent

One of the key points to a successful esophageal manometry study is to thoroughly explain the procedure beforehand to patients to bring down their anxiety levels. The prospect of having a tube passed through the nose and into the stomach can generate apprehension that can interfere with the technical quality of the study. Patients need to be assured that although they may be uncomfortable, it is not a painful study and they will not choke.

Pre-Procedure Planning

The patient should not have anything to eat or drink at least 4 hours prior to the procedure (diabetic patients should be NPO past midnight the night prior). Regular medications can be taken with a small amount of water. While some medications may alter esophageal motility (eg, antispasmodics, prokinetic agents, analgesics, sedatives), if the patient is taking them on a daily basis for a chronic condition, it makes sense to perform the study while the patient is on these medications, so as to factor in their systemic effects in the test results and decide and possible further therapy.

Equipment

Equipment for esophageal manometry includes the following:

  • Manometry catheter (either water-based or solid state system)
  • Manometer software with computer monitor
  • Lidocaine spray
  • Water-based lubricant
  • Glass of water with straw
  • 60-cc syringe
  • Normal saline solution (if performing manometry with impedance)
  • High ionic gel-consistency solution (for patient to swallow for impedance measurements)
  • Tape such as Transpore 3M TM (to secure manometry catheter to patient's nose throughout the procedure)
  • Tissues (to offer to patient as needed throughout the procedure)

As a side note, it is recommended that all liquids and disposable items be kept on a movable cart away from computer and electronic equipment.

Equipment is shown in the image below.

Equipment used for performing esophageal manometry Equipment used for performing esophageal manometry with impedance: lidocaine spray, water-based lubricant, syringe, normal saline solution, gel-consistency solution with high ionic content, tape, tissues, glass with water, and straw.

Patient Preparation

Anesthesia

Since the purpose of this procedure is to record esophageal pressures to further understand esophageal motility and function, it must be done in a patient who is fully awake and conscious. The areas through which the manometry catheter is going to be passed through are anesthetized with a topical anesthetic, such as lidocaine spray for the pharynx and viscous lidocaine for the sinuses.

Positioning

With the patient sitting upright, the pharynx and the nostril are anesthetized. In the same position, the catheter is passed through the nose, down the throat, and through the esophagus into the stomach while the patient takes small sips (as detailed in Technique).

Afterwards, the patient is asked to lay down; the motility testing itself of the lower esophageal sphincter and esophageal body function should always be performed in a supine patient. Although some esophageal motility laboratories continue to perform this study in the upright position, no set of upright normal values exist that could be comparable to established supine normal values.

Monitoring & Follow-up

The patient can resume his or her regular diet after the procedure. Any sore throat or discomfort can be alleviated by over-the-counter lozenges. The patient can usually expect a few days to pass before being notified of the results, as the study needs to be analyzed and interpreted by the technician and/or gastroenterologist.

Complications

This is a generally safe procedure, usually with few and mild complications such as gagging and watery eyes during the catheter insertion, sore throat, rhinorrhea, and epistaxis. Although rare in occurrence, more severe complications include arrhythmias, vasovagal episodes, bronchospasm, and aspiration. To our knowledge, there has only been a single report of esophageal perforation with this procedure.[5] In situations in which manometry has to be performed despite the presence of relative contraindications, precautions such as endoscopic or radiological guidance must be performed to decrease the risk of complications.

Common Manometric Abnormalities

Gastroesophageal Reflux Disease

Although one would assume that GERD should be consistently associated with low esophagogastric junction pressure, over 95% of these patients have a basal lower esophageal sphincter pressure greater than 10 mm Hg.[6] This is probably related to the fact that transient lower esophageal sphincter relaxation episodes can occur outside the timeframe in which the study is performed. Esophageal body peristalsis can also be impaired, with failed contractions of less than 30 mm Hg leading to impaired volume clearance (ie, ineffective esophageal motility). However, although these abnormalities are associated with GERD, they are not pathognomonic.

As far as its management, manometry is used in determining proper probe positioning for esophageal pH monitoring and aids in the preoperative and postoperative evaluation of antireflux surgery. However, there is a poor correlation between the results of the preoperative manometry and postoperative success and resolution of symptoms; it is mainly used to rule out other causes of symptoms if an alternative diagnosis is being considered.[7] After surgery, manometry can help determine whether the cause of dysphagia is related to an underlying motility problem or to a surgical complication.

Achalasia

The classic manometric findings of achalasia include smooth muscle esophageal aperistalsis and impaired relaxation of the lower esophageal sphincter/esophagogastric junction. The intramural myenteric plexus neurons that are absent in this condition promote lower esophageal sphincter relaxation and propagation of peristalsis, which explains these findings. Of note, a few manometric pattern variants of this condition exist, which show its complex nature.

In achalasia type I, there is no significant esophageal body pressurization; this subtype is more likely to present with endoscopic evidence of esophageal dilation. The manometric pattern of achalasia type II shows compartmentalized esophageal pressurization, which can span the whole length of the esophageal body; these patients are considered to have the best response rate out of the three to treatment. Achalasia type III is characterized by spastic contractions, which can even obliterate the esophageal lumen; this subtype is considered to be predictive of a lower treatment response than types I or II.[8] Despite this, further studies regarding the subclassification of achalasia are necessary to fully understand the different diagnostic and treatment strategies and the impact it has on patients' symptoms and disease course.[9]

See the images below.

High-resolution manometry of a patient with achala High-resolution manometry of a patient with achalasia type I. The top one third (in purple) represents a fluid-filled esophagus by impedance, with incomplete emptying between swallows. Below this, the upper horizontal dark-red band represents the upper esophageal sphincter; the orange band at the bottom with interspersed dark-red areas represents the lower esophageal sphincter. In between these 2 bands, it can be noted there is lack of pressurization and peristalsis in the esophageal body. Image courtesy of R. Matthew Gideon, MD, Albert Einstein Medical Center.
High-resolution manometry of a patient with achala High-resolution manometry of a patient with achalasia type II. The top one third (in purple) represents a fluid-filled esophagus by impedance. The bottom two thirds (in orange) represents a pressurized esophagus. The dark-red band at the top of the orange area represents the upper esophageal sphincter; the dark-red band at the bottom represents the lower esophageal sphincter. Note the isobaric simultaneous contractions and elevated intraesophageal pressure (orange area) along with impaired lower esophageal sphincter relaxation (high resting pressure and incomplete relaxation). Image courtesy of R. Matthew Gideon, MD, Albert Einstein Medical Center.
High-resolution manometry of a patient with achala High-resolution manometry of a patient with achalasia type III. The top one third represents the impedance portion of the study. In the bottom two thirds, in between the orange horizontal bars representing the upper and lower esophageal sphincter, the vertical bands that represent the esophageal body contractions can be seen. Note the maroon areas that are equivalent to a spastic contraction, which can even obliterate the esophageal lumen. Image courtesy of R. Matthew Gideon, MD, Albert Einstein Medical Center.

Isobaric simultaneous contractions and elevated intraesophageal pressure support the diagnosis of achalasia; however, these manometric findings are undistinguishable from Chagas disease. The presence of impaired lower esophageal sphincter relaxation differentiates achalasia from other conditions in which esophageal aperistalsis can be present (eg, diabetes, GERD), but is unable to distinguish it from Chagas disease.

Diffuse Esophageal Spasm

Diffuse esophageal spasm still has an unclear etiology, but what is known is that it is associated with intermittent abnormal esophageal contractions that can cause dysphagia and/or chest pain. Although the presence of simultaneous contractions is characteristic, up to 20% of healthy volunteers are found to have them in the absence of symptoms (likely due to their low amplitude). Some have recently proposed that a minimum amplitude of 20 mm Hg should be necessary for diagnosis.[10]

A further debate that has risen, however, is whether diffuse esophageal spasm should be considered a motor disorder in and of itself. If one limits the definition to meeting exactly all the criteria, it would be a very rare condition. If the defining parameters are broadened, it would be overdiagnosed.

Hypercontractile Motility Disorders

Included in the category of hypercontractile motility disorders are nutcracker esophagus (increased mean amplitude greater than 180 mm Hg with normal peristalsis and prolonged distal esophageal contraction) and hypertensive lower esophageal sphincter (resting pressure greater than 45 mm Hg with possible impaired relaxation). See the image below.

Tracings of a patient with nutcraker esophagus. In Tracings of a patient with nutcraker esophagus. Increased mean amplitude >180 mm Hg with normal peristalsis and prolonged distal esophageal contraction can be seen; the main problem stems from excess contractility either of the lower esophageal sphincter or esophageal body. Image courtesy of R. Matthew Gideon.

As the name suggests, the main problem in hypercontractile motility disorders stems from excess contractility either of the lower esophageal sphincter and/or esophageal body. These disorders are not fixed and may therefore vary and evolve into another form of motility disorder over time.

Hypocontractile Motility Disorders

The main problem in hypocontractile motility disorders is a lack of tone or contractility involving the lower esophageal sphincter or esophageal peristalsis. A hypotensive lower esophageal sphincter is defined by a resting pressure of less than 10 mm Hg, whereas ineffective esophageal motility is characterized by 30% or more low distal amplitude contractions (less than 30 mm Hg).

Multisystem/Collagen Vascular Diseases

The pattern observed in these cases include aperistalsis in the distal two-thirds of the esophagus (smooth muscle) and diminished or absent lower esophageal sphincter tone. In contrast, the upper esophageal sphincter tone and proximal esophageal function are preserved. However, this constellation is not pathognomonic for diagnosis and can be sometimes seen in other conditions, such as GERD.

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Technique

Approach Considerations

During the 1950s, different types of water-filled catheters were used for esophageal manometry studies. Although the initial technology was limited, it evolved in ways that allowed further understanding of esophageal motility and subsequent development of more sophisticated catheters. This system was used exclusively until the 1970s, when the first solid-state transducer was developed and slowly started to replace water-filled catheters as the preferred method. During the next 20 years, a number of studies were performed to try to establish what would be considered as normal values for esophageal pressure dynamics.

The esophageal manometry catheter has to be measured against a ruler prior to performing studies to verify accuracy. Whether a water-infusion or a solid-state catheter is used, the most distal recording point (perfusion port for the former, transducer for the latter) usually represents the zero point; usually when the catheter is introduced into the patient, the number seen at the nose corresponds to the measured distance to the zero point. The specific distances between the different transducers or infusion ports must also be known; nowadays modern computer software extrapolates the information regarding the space between the transducers.[11]

Another step to be performed prior to the study is calibration; that is, applying a known pressure to the transducers of the solid-state system by placing the catheter within a mercury manometer and seeing what number is actually displayed on the screen. The water-perfusion catheter is calibrated by recording pressures generated as air within the system is compressed. Failure to display the expected pressures should warrant further investigation prior to the study.[12]

Procedure

Help take the procedure off the patient's mind by actively involving them in the process. With the patient sitting up (having already anesthetized the nostril and the throat a couple of minutes before), have the patient hold a cup of water with a straw in one hand and the catheter connector in the other.

Apply a water-based lubricant to the first 5 cm of the catheter tip. With the chin slightly tilted down, begin to pass the catheter slowly through the sinuses. Point the catheter tip towards the patient's contrary earlobe as if crossing the floor of the sinuses. After passing the catheter about 12 cm, the tip will likely be at the level of the hypopharynx, in which it will usually not generate a gag reflex.

At this point, have the patient keep his or her shoulders down (to control gagging) and have them start taking small but continuous sips of water through the straw. Slowly start advancing the catheter 3 to 4 cm at a time. Drinking water in this fashion will help maintain relaxation of the lower esophageal sphincter while contractile activity in the esophageal body is inhibited.

The catheter will have reached the stomach when the most distal transducer shows an increase in pressure as it passes the lower esophageal sphincter, with a subsequent drop. Afterwards, place the patient in the supine position. Confirm that the transducers are in the stomach by asking the patient to take a deep breath; inspiration causes pressure in the abdominal cavity to rise, while expiration causes pressure to go down.

At this point, the catheter is withdrawn from the stomach 1 cm at a time, keeping watch for an increase in pressure that will signal when the transducer is crossing the lower esophageal sphincter. The tracing must be marked each time the catheter is moved.

With the most distal circumferential transducer in the lower esophageal sphincter, ten 5-mL water swallows are given to the patient with 15- 30 seconds in between to evaluate the lower esophageal sphincter relaxation pattern and contraction of the smooth muscle distal esophagus. After these sips, the catheter is further pulled out, 0.5 cm at a time, allowing the patient to take a few breaths between moves without swallowing (keeping the mouth slightly open suppresses the need to swallow).

The proximal lower esophageal sphincter border is at the point where the pattern changes to show thoracic pressures (decrease with inspiration, up on expiration). When the area of maximal upper esophageal sphincter pressure is reached, manipulate the catheter so as to place the most proximal transducer 1 cm below the sphincter. This time, five 5-mL water swallows are given; this allows evaluation of the skeletal muscle proximales.

Being able to pinpoint the location of the upper esophageal sphincter also aids in determining the length of the esophagus for subsequent pressure interpretation and possible pH probe positioning. To study the upper esophageal sphincter per se and the pharynx, the patient is then placed in an upright sitting position. The catheter is withdrawn in the same fashion as mentioned above until the distal transducer is located at the high pressure zone of the upper esophageal sphincter.

When the catheter reaches the proximal border of the sphincter, the pressure will drop. At this time, six 5-mL water swallows are performed. An M-shaped configuration pattern should be observed with each swallow as the upper esophageal sphincter elevates onto the transducer (first pressure spike), then relaxes (first pressure fall), closes (second pressure spike), and finally descends onto its original starting position (second pressure fall).

Analysis

As mentioned before, once the study is complete, the analysis of the recorded pressures and the knowledge of the distance between the recording points allows for analysis of the results. For example, assume the proximal lower esophageal sphincter was found at 46 cm and the distal lower esophageal sphincter was found at 50 cm. In this case, the lower esophageal sphincter is approximately 4 cm in length (50 – 46 = 4 cm).

Swallows were then performed with the distal transducer in the lower esophageal sphincter high-pressure zone at 47 cm, and with the transducers 5 cm apart within one another, the distal esophagus was studied with transducers at 42, 37, and 32 cm (ie, at 5, 10, and 15 cm above the lower esophageal sphincter).

Suppose the upper esophageal sphincter was then located at 18 cm from the nares and the proximal esophagus was studied at 19, 24, 29, and 34 cm (ie, 1, 6, 11, and 16 cm below the upper esophageal sphincter). By mapping out these locations, the esophageal length is calculated to be 28 cm by subtracting the proximal lower esophageal sphincter position from the upper esophageal sphincter location (46 –18 = 28 cm).

In plotting the transducer positions, one is able to see that some overlapped during the study and numbers obtained from them should be comparable. Esophageal length usually ranges between 18 and 28 cm, and the lower esophageal sphincter length between 3 and 5 cm.

Once the values are recorded within their anatomic location, further analysis ensues. Given the fact that manometric result recording is largely computer based, the option for automated analysis would be beneficial as it could potentially lead to a decrease in interoperator variability and further standardization of results. However, this has not been perfected to the point where it could substitute expert clinician analysis as clear cutoffs do not exist in certain areas where artifact could be distinguished from true peristaltic contractions.[13] .

One of the new advances in manometric data analysis is topographic data presentation through high-resolution manometry (see the image below).

High-resolution manometry catheter. Note the multi High-resolution manometry catheter. Note the multiple pressure transducers (unidirectional and circumferential) and impedance recording broad rings.

As the name implies, high-resolution manometry is a method of axial data interpolation derived from information obtained from multiple recording sites. The information is then presented as a 3-dimensional or 2-dimensional contour plot in which ranges of pressure amplitude are represented by color or grayscale gradient or concentric rings. This allows for a snapshot and dynamic representation of motility and peristalsis along the body of the esophagus.

Another technology that has been combined to the manometer over the last few years is intraluminal electrical impedance monitoring. This can be combined with either solid-state or water perfusion systems. It consists of pairs of metal rings dispersed along the catheter that quantify the impedance between them. Since air, fluids, and solids have unique impedance characteristics, the information provided allows the clinician to assess the effectiveness of intraluminal clearance and esophageal motor activity.

Manometric evaluation of the upper esophageal sphincter is complicated by its asymmetric and complex anatomy and the fact that it moves during swallowing. The presence of the catheter itself also stimulates its contraction. Proximal esophageal contractions can be assessed for amplitude, but the normal values are not known; the clinical utility of this evaluation is therefore somewhat limited. However, when this is combined with concurrent fluoroscopy, it provides added insight into the understanding and evaluation of problems like Zenker diverticula and cricopharyngeal bars.

Regarding the esophageal body, manometry has shown that bolus transit through the esophageal body does not occur in a single smooth wave, but rather represents a sequence of contractions that occur within 4 pressure segments extending from the upper esophageal sphincter to the lower esophageal sphincter. Associated with proper distal esophageal emptying is a peristaltic amplitude of greater than 30 mm Hg; this cutoff has a specificity of 66% and a sensitivity of 85% for identifying incomplete bolus transit.

The esophagogastric junction pressures are a result of the combination of the intrinsic lower esophageal sphincter tone with pressure contributed by the right crus of the diaphragm; this allows for a wide range in what is considered normal values within end inspiration and end expiration. However, a significantly low value (less than 5 mm Hg) is definitely considered abnormal.

Additionally, the most important measurement obtained during esophageal manometry is probably the value of lower esophageal sphincter relaxation; advances in determining what is considered normal values have been greatly achieved after the introduction of high-resolution manometry.

The table below summarizes some values used to determine normal esophageal function and primary motility disorders.

Table. Criteria for Normal Esophageal Function and Primary Motility Disorders (Open Table in a new window)

Motility pattern LES resting pressure



(10-45 mm Hg)



LES relaxation residual



(≤8 mm Hg)



Effective peristaltic waves (≥ 30 mm Hg) Ineffective peristaltic wavesa (< 30 mm Hg) Simultaneous contractions (> 30 mm Hg) propagation rate ≥ 8cm/sec
Normal 10-45 mm Hg ≤8 mm Hg ≥7 waves ≤2 waves ≤ 1 contraction
Achalasia Normal (≤45 mm Hg)



Abnormal (>45 mm Hg)



>8 mm Hg 0 0 10 contractions
Distal esophageal spasm Normal (≤45 mm Hg)



Abnormal (>45 mm Hg)



Normal



(≤8 mm Hg)



Abnormal



(>8 mm Hg)



1-8 ≤2 waves ≥2 contractions



≤9 contractions



Hypercontractile motility



Hypertensive LES



Nutcracker esophagus



 



>45 mm Hg



 



≤8 mm Hg



 



7-10 wavesb



 



≤2 waves



 



≤1 contraction



Hypocontractile motility



Hypotensive LES



Ineffective esophageal motility



 



< 10 mm Hg



 



≤8 mm Hg



 



0-7 waves



 



3-10 waves



 



≤1 contraction



a 3 and/or 8 cm above the lower esophageal sphincter.



b Average amplitude of 10 swallows (20 contractions 3 and 8 cm above the lower esophageal sphincter) greater than 180 mm Hg.



LES, lower esophageal sphincter.



Data from Gideon RM. Manometry: Technical issues. Gastrointest Endoscopy Clin N Am 2005;15:243-255.



Of note, for reasons that are still not completely understood, when high-resolution manometry is used compared to the solid-state system with regular pressure tracings, the lower esophageal sphincter relaxation residual value changes from less than 8 mm Hg to less than 15 mm Hg; the rest of the values remain the same. See the image below.

Normal high-resolution manometry with impedance. T Normal high-resolution manometry with impedance. The upper one third of the image represents the impedance portion, where purple bands representing the passage of a bolus are separated by white areas that represent complete esophageal emptying. In the lower two thirds of the image, note the normal upper esophageal resting pressure with complete relaxation (top orange band) followed by progressive peristaltic waves of the esophageal body (orange vertical bands) and subsequent lower esophageal relaxation. Note the absence of pressurized esophagus in between swallows, represented by the blue-green areas in between. Lower esophageal sphincter pressure returns to baseline after the bolus passes (lower orange band). The sequence is seen over and over. Image courtesy of R. Matthew Gideon, MD, Albert Einstein Medical Center.
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Contributor Information and Disclosures
Author

Philip O Katz, MD, FACP, FACG Chairman, Division of Gastroenterology, Albert Einstein Medical Center; Clinical Professor of Medicine, Jefferson Medical College of Thomas Jefferson University

Philip O Katz, MD, FACP, FACG is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Received honoraria from Takeda for speaking and teaching; Received consulting fee from Ironwood for consulting; Received consulting fee from Torax for consulting; Received consulting fee from Pfizer Consumer Health for consulting.

Coauthor(s)

Mildred D Garcia Rodriguez, MD Fellow, Department of Medicine, Division of Gastroenterology, Albert Einstein Medical Center

Mildred D Garcia Rodriguez, MD is a member of the following medical societies: American College of Physicians, American Gastroenterological Association

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

References
  1. American Gastroenterological Association medical position statement: Clinical use of esophageal manometry. Gastroenterology. 2005 Jan. 128(1):207-8. [Medline].

  2. Gomez J, Sachdeva P, Parkman HP. Esophageal Manometry. Parkman HP, McCallum RW, Rao SSC. GI Motility Testing: A Laboratory and Office Handbook. 1. Thorofare, NJ: SLACK Incorporated; 2011. chap 1.

  3. Kronecker H, Meltzer SJ. Der Schluckmechanisms, seine erregung and seine hummung. Arch Ges Anat Physiol. 1883. 7(Suppl):328-32.

  4. Meltzer SJ. Recent experimental contributions to the physiology of deglutition. N Y State J Med. 1894. 59:389-92.

  5. Meister V, Schulz H, Greving I, Imhoff M, Walter LD, May B. [Perforation of the esophagus after esophageal manometry]. Dtsch Med Wochenschr. 1997 Nov 14. 122(46):1410-4. [Medline].

  6. Behar J, Biancani P, Sheahan DG. Evaluation of esophageal tests in the diagnosis of reflux esophagitis. Gastroenterology. 1976 Jul. 71(1):9-15. [Medline].

  7. Patti MG, Perretta S, Fisichella PM, D'Avanzo A, Galvani C, Gorodner V, et al. Laparoscopic antireflux surgery: preoperative lower esophageal sphincter pressure does not affect outcome. Surg Endosc. 2003. 17:386-389.

  8. Pandolfino JE, Kwiatek MA, Nealis T, Bulsiewicz W, Post J, Kahrilas PJ. Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology. 2008 Nov. 135(5):1526-33. [Medline].

  9. Wang A, Pleskow DK, Banerjee S, Barth BA, Bhat YM. Esophageal function testing. Gastrointest Endosc. 2012 Aug. 76(2):231-43. [Medline].

  10. Spechler SJ, Castell DO. Classification of oesophageal motility abnormalities. Gut. 2001. 49:145-151.

  11. Gideon RM. Manometry: technical issues. Gastrointest Endoscopy Clin N Am. 2005. 15:243-255.

  12. Tutuian R, Elton JP, Castell DO, Gideon RM, Castell JA, Katz PO. Effects of position on oesophageal function: studies using combined manometry and multichannel intraluminal impedance. Neurogastroenterol Motil. 2003 Feb. 15(1):63-7. [Medline].

  13. AGA technical review on the clinical use of esophageal manometry. Gastroenterology. 2005 Jan. 128(1):209-24. [Medline].

 
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Equipment used for performing esophageal manometry with impedance: lidocaine spray, water-based lubricant, syringe, normal saline solution, gel-consistency solution with high ionic content, tape, tissues, glass with water, and straw.
Solid-state manometry catheter. Note that the catheter has a memory, and its tip tends to point slightly to one side. This plays a role when difficulty passing the catheter is encountered, as rotating it slightly may send the catheter in a different direction and facilitate the procedure.
High-resolution manometry catheter. Note the multiple pressure transducers (unidirectional and circumferential) and impedance recording broad rings.
High-resolution manometry system, including a computer system that allows graphical display of tracings.
Normal high-resolution manometry with impedance. The upper one third of the image represents the impedance portion, where purple bands representing the passage of a bolus are separated by white areas that represent complete esophageal emptying. In the lower two thirds of the image, note the normal upper esophageal resting pressure with complete relaxation (top orange band) followed by progressive peristaltic waves of the esophageal body (orange vertical bands) and subsequent lower esophageal relaxation. Note the absence of pressurized esophagus in between swallows, represented by the blue-green areas in between. Lower esophageal sphincter pressure returns to baseline after the bolus passes (lower orange band). The sequence is seen over and over. Image courtesy of R. Matthew Gideon, MD, Albert Einstein Medical Center.
High-resolution manometry of a patient with achalasia type II. The top one third (in purple) represents a fluid-filled esophagus by impedance. The bottom two thirds (in orange) represents a pressurized esophagus. The dark-red band at the top of the orange area represents the upper esophageal sphincter; the dark-red band at the bottom represents the lower esophageal sphincter. Note the isobaric simultaneous contractions and elevated intraesophageal pressure (orange area) along with impaired lower esophageal sphincter relaxation (high resting pressure and incomplete relaxation). Image courtesy of R. Matthew Gideon, MD, Albert Einstein Medical Center.
Pressure tracings obtained from solid-state manometry system in a patient with achalasia. To the untrained eye, the abnormality may be easier to see with the high-resolution manometry images. Again, it shows isobaric esophageal body contractions and impaired lower esophageal sphincter relaxation. Image courtesy of R. Matthew Gideon.
Tracings of a patient with nutcraker esophagus. Increased mean amplitude >180 mm Hg with normal peristalsis and prolonged distal esophageal contraction can be seen; the main problem stems from excess contractility either of the lower esophageal sphincter or esophageal body. Image courtesy of R. Matthew Gideon.
High-resolution manometry of a patient with achalasia type I. The top one third (in purple) represents a fluid-filled esophagus by impedance, with incomplete emptying between swallows. Below this, the upper horizontal dark-red band represents the upper esophageal sphincter; the orange band at the bottom with interspersed dark-red areas represents the lower esophageal sphincter. In between these 2 bands, it can be noted there is lack of pressurization and peristalsis in the esophageal body. Image courtesy of R. Matthew Gideon, MD, Albert Einstein Medical Center.
High-resolution manometry of a patient with achalasia type III. The top one third represents the impedance portion of the study. In the bottom two thirds, in between the orange horizontal bars representing the upper and lower esophageal sphincter, the vertical bands that represent the esophageal body contractions can be seen. Note the maroon areas that are equivalent to a spastic contraction, which can even obliterate the esophageal lumen. Image courtesy of R. Matthew Gideon, MD, Albert Einstein Medical Center.
Table. Criteria for Normal Esophageal Function and Primary Motility Disorders
Motility pattern LES resting pressure



(10-45 mm Hg)



LES relaxation residual



(≤8 mm Hg)



Effective peristaltic waves (≥ 30 mm Hg) Ineffective peristaltic wavesa (< 30 mm Hg) Simultaneous contractions (> 30 mm Hg) propagation rate ≥ 8cm/sec
Normal 10-45 mm Hg ≤8 mm Hg ≥7 waves ≤2 waves ≤ 1 contraction
Achalasia Normal (≤45 mm Hg)



Abnormal (>45 mm Hg)



>8 mm Hg 0 0 10 contractions
Distal esophageal spasm Normal (≤45 mm Hg)



Abnormal (>45 mm Hg)



Normal



(≤8 mm Hg)



Abnormal



(>8 mm Hg)



1-8 ≤2 waves ≥2 contractions



≤9 contractions



Hypercontractile motility



Hypertensive LES



Nutcracker esophagus



 



>45 mm Hg



 



≤8 mm Hg



 



7-10 wavesb



 



≤2 waves



 



≤1 contraction



Hypocontractile motility



Hypotensive LES



Ineffective esophageal motility



 



< 10 mm Hg



 



≤8 mm Hg



 



0-7 waves



 



3-10 waves



 



≤1 contraction



a 3 and/or 8 cm above the lower esophageal sphincter.



b Average amplitude of 10 swallows (20 contractions 3 and 8 cm above the lower esophageal sphincter) greater than 180 mm Hg.



LES, lower esophageal sphincter.



Data from Gideon RM. Manometry: Technical issues. Gastrointest Endoscopy Clin N Am 2005;15:243-255.



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