Background

Esophageal manometry measures the different factors that play a role in the motility and function of the upper esophageal sphincter (UES), the body of the esophagus, and the lower esophageal sphincter (LES).^{[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 the technology that would allow a proper recording of esophageal pressure dynamics was not developed until the 1970s.

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 ^[5] or another type of nonobstructive dysphagia
Preoperative evaluation for patients undergoing corrective surgery for GERD, particularly if an alternative diagnosis like scleroderma or achalasia is being considered ^[6]
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 LES for proper electrode positioning
Evaluation of esophageal motility problems associated with systemic diseases

According to the Lyon Consensus,^[7]high-resolution manometry (HRM) is not useful for the direct diagnosis of GERD but can be useful in the setting of GERD by providing adjunctive information (eg, on esophagogastric junction [EGJ] barrier function, esophageal body motor function, contractile function, or EGJ obstruction). American College of Gastroenterology (ACG) guidelines do not recommend HRM solely as a diagnostic test for GERD.^[6]

A study of patients who underwent protocolized videoesophagography (VEG) and manometry in preparation for foregut surgery found that routine manometry was not warranted in patients with normal VEG and suggested that it should be reserved for patients with abnormal VEG.^[8]

Contraindications

Esophageal manometry is contraindicated in the following situations:

Patients with altered mental status or obtundation
Patients who cannot understand or follow instructions
Suspected or known pharyngeal or upper esophageal obstruction (eg, tumors)

Procedural 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 one encounters problems or resistance that cannot be overcome with reasonable pressure while trying to pass the manometry catheter through the nostrils (particularly in patients with prior nasal surgery, deformation, or small nares), the catheter can instead be introduced through the mouth. This will avoid lesions caused by forcing the catheter against resistance.

Periprocedure

Pandolfino JE, Kahrilas PJ, American Gastroenterological Association. American Gastroenterological Association medical position statement: Clinical use of esophageal manometry. Gastroenterology. 2005 Jan. 128 (1):207-8. [QxMD MEDLINE Link].
Gomez J, Sachdeva P, Parkman HP. Esophageal manometry. Parkman HP, McCallum RW, Rao SSC, eds. GI Motility Testing: A Laboratory and Office Handbook. Thorofare, NJ: SLACK; 2011. 15-24.
Kronecker H, Meltzer SJ. Der Schluckmechanismus, seine Erregung and seine Hummung. Arch Ges Anat Physiol. 1883. 7 (Suppl):328-32.
Meltzer SJ. Recent experimental contributions to the physiology of deglutition. N Y State J Med. 1894. 59:389-92.
[Guideline] Stefanidis D, Richardson W, Farrell TM, Kohn GP, Augenstein V, Fanelli RD. Guidelines for the surgical treatment of esophageal achalasia. Society of American Gastrointestinal and Endoscopic Surgeons. Available at http://www.sages.org/publications/guidelines/guidelines-for-the-surgical-treatment-of-esophageal-achalasia. May 2011; Accessed: May 25, 2022.
[Guideline] Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2022 Jan 1. 117 (1):27-56. [QxMD MEDLINE Link]. [Full Text].
Gyawali CP, Kahrilas PJ, Savarino E, Zerbib F, Mion F, Smout AJPM, et al. Modern diagnosis of GERD: the Lyon Consensus. Gut. 2018 Jul. 67 (7):1351-1362. [QxMD MEDLINE Link]. [Full Text].
Alicuben ET, Bildzukewicz N, Samakar K, Katkhouda N, Dobrowolsky A, Sandhu K, et al. Routine esophageal manometry is not useful in patients with normal videoesophagram. Surg Endosc. 2019 May. 33 (5):1650-1653. [QxMD MEDLINE Link].
Dhawan I, O'Connell B, Patel A, Schey R, Parkman HP, Friedenberg F. Utility of Esophageal High-Resolution Manometry in Clinical Practice: First, Do HRM. Dig Dis Sci. 2018 Dec. 63 (12):3178-3186. [QxMD MEDLINE Link].
Gideon RM. Manometry: technical issues. Gastrointest Endosc Clin N Am. 2005 Apr. 15 (2):243-55. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Pandolfino JE, Kahrilas PJ, American Gastroenterological Association. AGA technical review on the clinical use of esophageal manometry. Gastroenterology. 2005 Jan. 128 (1):209-24. [QxMD MEDLINE Link].
Meyer JP, Jones CA, Walczak CC, McCulloch TM. Three-dimensional manometry of the upper esophageal sphincter in swallowing and nonswallowing tasks. Laryngoscope. 2016 Nov. 126 (11):2539-2545. [QxMD MEDLINE Link].
Roman S, Huot L, Zerbib F, Bruley des Varannes S, Gourcerol G, Coffin B, et al. High-Resolution Manometry Improves the Diagnosis of Esophageal Motility Disorders in Patients With Dysphagia: A Randomized Multicenter Study. Am J Gastroenterol. 2016 Mar. 111 (3):372-80. [QxMD MEDLINE Link].
Yadlapati R, Kahrilas PJ, Fox MR, Bredenoord AJ, Prakash Gyawali C, Roman S, et al. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0^©. Neurogastroenterol Motil. 2021 Jan. 33 (1):e14058. [QxMD MEDLINE Link]. [Full Text].
Behar J, Biancani P, Sheahan DG. Evaluation of esophageal tests in the diagnosis of reflux esophagitis. Gastroenterology. 1976 Jul. 71 (1):9-15. [QxMD MEDLINE Link].
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 Mar. 17 (3):386-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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[Guideline] Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013 Mar. 108 (3):308-28; quiz 329. [QxMD MEDLINE Link].

Media Gallery

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 catheter has memory, and its tip tends to point slightly to one side. This is significant when difficulty passing the catheter is encountered; rotating it slightly may send catheter in different direction and facilitate the procedure.
High-resolution manometry catheter. Note multiple pressure transducers (unidirectional and circumferential) and impedance recording broad rings.
High-resolution manometry system, including computer system that allows graphical display of tracings.
Normal high-resolution manometry with impedance. Upper one third of image represents impedance portion, where purple bands representing passage of bolus are separated by white areas that represent complete esophageal emptying. In lower two thirds of image, note normal upper esophageal resting pressure with complete relaxation (top orange band) followed by progressive peristaltic waves of esophageal body (orange vertical bands) and subsequent lower esophageal relaxation. Note absence of pressurized esophagus in between swallows, represented by blue-green areas in between. Lower esophageal sphincter pressure returns to baseline after bolus passes (lower orange band). This sequence is seen over and over. Image courtesy of R Matthew Gideon, Albert Einstein Medical Center.
High-resolution manometry of patient with achalasia type II. Top one third (in purple) represents fluid-filled esophagus by impedance. Bottom two thirds (in orange) represents pressurized esophagus. Dark-red band at top of orange area represents upper esophageal sphincter (UES); dark-red band at bottom represents lower esophageal sphincter (LES). Note isobaric simultaneous contractions and elevated intraesophageal pressure (orange area) along with impaired LES relaxation (high resting pressure and incomplete relaxation). Image courtesy of R Matthew Gideon, Albert Einstein Medical Center.
Pressure tracings obtained from solid-state manometry system in patient with achalasia. To untrained eyes, abnormality may be easier to see with high-resolution manometry images. Again, it shows isobaric esophageal body contractions and impaired lower esophageal sphincter relaxation. Image courtesy of R Matthew Gideon, Albert Einstein Medical Center.
Tracings of patient with nutcracker esophagus. Increased mean amplitude >180 mm Hg with normal peristalsis and prolonged distal esophageal contraction can be seen; main problem stems from excess contractility either of lower esophageal sphincter or of esophageal body. Image courtesy of R Matthew Gideon, Albert Einstein Medical Center.
High-resolution manometry of patient with achalasia type I. Top one third (in purple) represents fluid-filled esophagus by impedance, with incomplete emptying between swallows. Below this, upper horizontal dark-red band represents upper esophageal sphincter; orange band at bottom with interspersed dark-red areas represents lower esophageal sphincter. In between these two bands, it can be noted that there is no panesophageal pressurization and no peristalsis in the esophageal body. Image courtesy of R Matthew Gideon, Albert Einstein Medical Center.
High-resolution manometry of patient with achalasia type III. Top one third represents impedance portion of study. In bottom two thirds, in between orange horizontal bars representing upper and lower esophageal sphincters, vertical bands that represent esophageal body contractions can be seen. Note areas that are equivalent to spastic contraction, which can even obliterate esophageal lumen. Image courtesy of R Matthew Gideon, Albert Einstein Medical Center.
Representative swallow in patient with diagnosed jackhammer esophagus. DCI is 19,852 mm Hg∙s∙cm with IRP of 13.6 mm Hg. In this swallow, lower esophageal sphincter exhibits contractility and is included in calculation of DCI.

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Table 1. Criteria for Normal Esophageal Function and Primary Motility Disorders

Table 1. Criteria for Normal Esophageal Function and Primary Motility Disorders

Motility pattern	LES resting pressure (10-45 mm Hg)	LES relaxation residual (≤ 8 mm Hg or, in HRM, < 15 mm Hg^a or ≤ 20 mm Hg^b)	Effective peristaltic waves in distal esophagus (≥30 mm Hg) at 5 and 10 cm above LES	Ineffective peristaltic waves in distal esophagus (< 30 mm Hg) at 3 and/or 8 cm above LES	Simultaneous contractions (>30 mm Hg) at propagation rate ≥8 cm/s
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)	Normal (≤ 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 waves^c	≤ 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 LES integrated relaxation pressure in medtronic HRM system. ^b LES integrated relaxation pressure in Sandhill HRM system. ^c Average amplitude of 10 swallows (20 contractions 5 and 10 cm above LES) >180 mm Hg. LES = lower esophageal sphincter. Data from Gideon RM. Manometry: Technical issues. Gastrointest Endoscopy Clin N Am 2005;15:243-255.