Patient Education and Consent

One of the key aspects of a successful esophageal manometry study is to thoroughly explain the procedure beforehand to patients so as 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.

Preprocedural Planning

The patient should not have anything to eat or drink for at least 4 hours before the procedure (diabetic patients should take nothing orally after midnight the night before).

Regular medications can be taken with a small amount of water. Although some medications may alter esophageal motility (eg, antispasmodics, prokinetic agents, analgesics, opiates, or sedatives), if the patient is taking them on a daily basis for a chronic condition, it may make 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 on possible further therapy. Because it is difficult to interpret abnormalities in the setting of these medications, repeat procedures off therapy may be required.

Equipment

Equipment for esophageal manometry includes the following:

Manometry catheter - High-resolution manometry (HRM) is the current standard ^[9]; solid-state systems are acceptable if no other equipment is available
Manometer software with computer monitor
Lidocaine spray
Water-based lubricant
Glass of water with straw
Syringe, 60 mL
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 the manometry catheter to the 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 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.

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Anesthesia

Because the purpose of esophageal manometry is to record esophageal pressures for further understanding of esophageal motility and function, the procedure must be done in a patient who is fully awake and conscious. The areas through which the manometry catheter will be passed 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 (see Technique).

Afterward, the patient is asked to lay down; motility testing of the lower esophageal sphincter (LES) 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 exists 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; the study must be analyzed and interpreted by the technician, the gastroenterologist, or both.

Technique

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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.