1. Esophageal Manometry Kevin Kolendich, MD Gastroenterology and Hepatology Missoula Medical Conference October 24th , 2014

2. Financial Disclosures
No financial disclosures

3. A Little Background on Me

4. St. Patrick Hospital
St. Patrick Hospital is a 213-bed hospital with a level 2 trauma center. St. Patrick currently has 1,400 employees and 266 physicians.

5. St. Patrick Hospital St. Patrick Hospital Motility Team.
Jenifer Alsbury, RN
Tamara Keogh, RN
Christi Brinda, RN
High volume motility center.

6. Esophageal Manometry

7. Esophageal Manometry Definition
A diagnostic test in which a thin tube is passed into the esophagus to measure the pressures exerted by the muscles of the esophagus over time during a swallow.

8. Is this how esophageal manometry appears to you?

9. Once understood, manometry is so simple that anyone can do it

10. What are the learning objectives from today’s lecture?

11. Learning Objectives Describe normal esophageal anatomy.
Understand the difference between water perfused manometry and solid state esophageal manometry.

12. Learning Objectives
Be able to properly identify and mark the following anatomic landmarks using high resolution manometry.
The upper esophageal sphincter (UES)
The esophageal body
The esophago-gastric junction (EGJ)
Be able to describe patient preparation for esophageal manometry.

13. Learning Objectives
Be able to describe how an esophageal motility catheter is placed.
Understand when to refer patients for esophageal manometry.
Know where to find resources to further your understanding of manometry.

14. Describe normal esophageal anatomy

15. Normal Esophageal Anatomy

16. Normal Esophageal Anatomy
Upper Esophageal Sphincter (UES)
Cervical esophagus
Cricopharyngeus
Inferior pharyngeal constrictor

17. Normal Esophageal Anatomy
Esophageal body
The proximal 5% is striated muscle.
The middle 35%-40% is mixed (transition zone).
The distal 50%-60% is entirely smooth muscle.

18. Normal Esophageal Anatomy
Muscular composition
Outer layer (longitudinal).
Inner layer (circular).
more precisely helical muscle.

19. Clinical Correlation Clinical Correlation:
Presbyesophagus also known as tertiary contractions

20. Normal Esophageal Anatomy
There are three major contributors to the EGJ high pressure zone.
1. The LES
2. The crural diaphragm
3. The muscular architecture of the gastric cardia

21. Understand the difference between water perfused manometry and solid state esophageal manometry

22. Manometry Water Perfusion Manometry (Conventional).
Every 5 cm
Solid State Manometry (High Resolution, 3D).
Every 1 cm

23. Equipment – Conventional Manometry
8 channels, 4 are located 5 cm from the tip of the catheter with 4 other more proximal sensors spaced 5 cm apart.
3.9 mm diameter.

24. Conventional Manometry

25. Equipment – High Resolution Manometry
All sensors are truly circumferential .
36 channels spaced 1 cm apart 12 pressure sensing points at each channel (432 data points) .
Small diameter
2.75 mm.
Source:

26. High Resolution Manometry
Magenta end of color spectrum
(hot colors) = highest pressure.
Blue end of color spectrum
(cool colors) = lowest pressure.

27. High Resolution Manometry

28. Discuss the advantages high resolution manometry has over conventional esophageal manometry.

29. High Resolution Manometry vs. Conventional Manometry
Need to move catheter for LES in most systems
Water-perfusion systems are multicomponent and cumbersome
Low fidelity
Waveforms only
LES measurements complex; some use sleeves, others need station pull-through technique
Hard to find hiatal hernias
Water-perfused catheters are stiff and more uncomfortable
Tests take longer
Large gaps between channels (5 cm)
Catheter stays in one position
Solid state systems are relatively simple and less cumbersome
High fidelity
Color contour
No need for pull through: software creates an electronic sleeve for LES determination
Hiatal hernias are easily identified
Solid state catheters are soft and more comfortable
Procedure takes less time
Array of 36 channels straddle the entire esophagus, sees the entire organ

30. High Resolution Manometry vs. Conventional Manometry

31. Patient Preparation for High Resolution Esophageal Manometry

32. Pre-Pr0cedure Counseling
How do you describe esophageal manometry to a patient?
During esophageal manometry, a thin, pressure-sensitive, flexible tube is passed through your nose and into your stomach.
When the tube is in your esophagus, you will be asked to swallow. The pressure of the muscle contractions will be measured along the length of your esophagus.
The tube is removed after the test is completed. The test takes about 1 hour.

33. Pre-Pr0cedure Counseling
How do you tell patients to prepare for a manometry?
Patients should not have anything to eat or drink for 4-6 hours before the test (varies by center).
There is no need for bowel preparation.
Take all prescribed medications as usual.
This includes anticoagulants, aspirin, and NSAIDs, acid suppressive therapy.

34. Pre-Pr0cedure Counseling
How will the test feel?
Typically, the test is not uncomfortable.
Some patients may experience a gagging sensation when the tube is being placed.

35. How is an Esophageal Manometry Probe Placed?

36. Catheter Placement
Before bringing the patient into the room an RN performs a focused H&P and chart review.
Indication (dysphagia, chest pain, pre-operative evaluation, etc.)
Allergies (assure the patient isn’t allergic to lidocaine)
If they are use sterile lubricant jelly
Pertinent past surgeries (Nasal, esophageal, bariatric surgery etc.)
Make sure the patient did not eat or drink anything for 4 to 6 hours prior to test (this varies by center).

37. Catheter Placement The patient is brought into the procedure room.
A gown is placed over their upper body and they sit on the edge of a gurney.
The patient occludes each nostril and sniffs to determine if their right or left nostril is more patent.

38. Catheter Placement
The nostril is numbed with 2% lidocaine jelly using a 6-inch cotton tip applicator.
The manometric catheter is lubricated with 2% lidocaine.

39. Catheter Placement The patient brings their chin down to their chest.
The catheter is advanced through the medicated nostril into the esophagus while the patient swallows.

40. Catheter Placement
The manometric catheter is advanced until it crosses the lower esophageal sphincter and its distal tip is in the stomach.
The catheter is secured in place with tape.
The patient then lies supine on a gurney.

41. Catheter Placement
5 ml of water (or saline) is placed into the patient’s mouth using a syringe.
The patient holds the liquid in their mouth then swallows once.
30 seconds later this is repeated.
10 wet swallows are performed.
The catheter is removed.

42. Describe the manometric findings present during a normal swallow. 1
Describe the manometric findings present during a normal swallow. 1. LES relaxation 2. Normal esophageal peristalsis 3. UES relaxation

43. The Esophagus at Rest

44. Manometry Tracing

45. Name the indications for esophageal manometry

46. Indications Dysphagia. Non-cardiac chest pain.
Placement of intraluminal devices (e.g. pH probes).
Preoperative assessment of patients being considered for anti-reflux surgery and bariatric surgery.
Detecting esophageal motor abnormalities associated with systemic diseases (e.g. connective tissue diseases).
American Gastroenterological Association Patient Care Committee on May 15, 1994

47. Dysphagia
The first step is to distinguish between oropharyngeal dysphagia and esophageal dysphagia.
Oropharyngeal dysphagia:
Arises from dysfunction of the pharynx and upper esophageal sphincter.
Esophageal dysphagia:
Arises from disorders of the esophageal body and lower esophageal sphincter.

48. Dysphagia Have difficulty initiating a swallow.
Oropharyngeal
Esophageal
Have difficulty initiating a swallow.
Localize symptoms to the cervical region.
Frequently associated with coughing, choking, nasal regurgitation, and dysphonia.
Have difficulty swallowing several seconds after initiating a swallow.
Localize symptoms to the suprasternal notch or behind the sternum.
May be associated with a history of food impaction or food “sticking” in the chest.

49. What are some the appropriate questions to ask a patient with dysphagia in the office?

50. Dysphagia
Do you have problems initiating a swallow or do you feel food getting stuck a few seconds after swallowing?
Do you cough or choke or is food coming back through your nose after swallowing?
Do you have problem swallowing solids, liquids, or both?
How long have you had problems swallowing and have your symptoms progressed, remained stable, or are they intermittent?

51. Dysphagia Could you point to where you feel food is getting stuck?
What medications are you using now?
potassium chloride
alendronate
ferrous sulfate
quinidine
ascorbic acid
tetracycline
aspirin
NSAIDs

52. Dysphagia Upper Endoscopy:
Patients with suspected esophageal dysphagia should be referred for an upper endoscopy as the initial test.
Structural assessment.
Has the advantage that biopsies can be obtained and intervention performed.

53. Dysphagia Barium swallow:
This is a good second test following a negative upper endoscopy if a mechanical obstruction is still suspected.
External compression.
B rings (Schatzki ring) can be missed.
Zenker’s diverticulum
Cricopharyngeal bar
Structural and functional assessment.
Can assess the UES and pharynx more reliably than upper endoscopy.

54. Dysphagia Esophageal Manometry:
Motility testing should be performed in patients with dysphagia in whom upper endoscopy is unrevealing and/or an esophageal motility disorder is suspected.
Functional assessment.

55. Case #1
47 year old woman with 2 years progressive dysphagia to solids and liquids. After meals she has a sensation of fullness in her chest . She often drinks water to make solid food pass.
A recent EGD was normal thus she was referred for esophageal manometry.

56. Achalasia - Type II Normal
Mean IRP > upper limits of normal (incomplete LES relaxation)
Absence of esophageal peristalsis (note: specifics vary for type I, II, and III achalasia)
Normal

57. Case #1
The patient underwent pneumatic dilation of her LES to 30 mm with marked improvement in her symptoms.
Therapeutic options
Heller myotomy
Pneumatic dilation
Botox injection into the LES
POEM (Per Oral Endoscopic Myotomy)

58. Chest Pain
An esophageal source of chest pain should be considered only after cardiopulmonary factors have been carefully investigated.

59. Chest Pain
A patient should first undergo an upper endoscopy and exclusion of GERD.
GERD is the most common cause of non-cardiac chest pain.
GERD is much more common than an esophageal motility disorder.

60. Case #2
A 84 year old male complains of severe chest pain which onsets during meals.
EGD, CT abd/pelvis, barium esophagram, and 24 hour ph study are all normal. A cardiac work-up and which includes a nuclear perfusion test is normal. He is told by an ER physician that his symptoms are stress induced and “in his head”.
The patient is referred by his PCP for esophageal manometry.

61. Jackhammer Esophagus
DCI > 8,000 mmHg-cm-s (hypercontractile esophagus)
Normal mean IRP (the EGJ relaxes normally)

62. Case #2
He initially is treated with diltiazem which causes intolerable hypotension and orthostasis. This medication is stopped and he undergoes EGD with botox injection into the LES with complete resolution of his symptoms.
Therapy
Rule out EGJ outflow obstruction causing reactive hypercontractile peristalsis
Treat GERD if present
Calcium Channel blockers (Diltiazem)
Nitrates (Isosorbide dinitrate)
Sildenafil
Botox injection into the LES

63. Prior to Anti-reflux Surgery
The most important role of esophageal manometry in patients with GERD has traditionally been for evaluation prior to antireflux surgery.

64. Prior to Anti-reflux Surgery
Why is esophageal manometry done prior to esophageal or gastric surgery?

65. Prior to Anti-reflux Surgery
Manometry may lead to a modification of the surgical approach.

66. Prior to Anti-reflux Surgery
Esopahgeal manometry may lead to an alternative diagnosis such as scleroderma or achalasia.

67. Prior to Anti-reflux Surgery
Evaluation of post operative symptoms.
The best way to determine if a surgery is causal of a manometric abnormality is comparison of a patient’s pre-operative manometry study to their post-operative manometry study.

68. Case #3
42 year old woman with long standing heartburn which has had relatively little improvement despite trials of omeprazole, esomeprazole, and dexlansoprazole.
Upper endoscopy reveals a small sliding hiatal hernia with LA class A erosive esophagitis.
She is referred to a surgeon for consideration of fundoplication. Her surgeon orders pre-operative esophageal manometry and pH testing.

69. Jackhammer Esophagus
DCI > 8,000 mmHg-cm-s (hypercontractile esophagus)
Normal mean IRP (the EGJ relaxes normally)

70. Case #3
The patient was treated for a hypercontractile esophageal disorder with a calcium channel blocker with a significant reduction in symptoms.

71. Case #4
A 49 year old woman with GERD complains of severe heartburn. This improves with twice daily PPI therapy and lifestyle modification, however severe nocturnal symptoms persist.
EGD reveals a hiatal hernia and LA class C esophagitis despite compliance with BID PPI.
She is referred to a surgeon for consideration of fundoplication. Her surgeon orders pre-operative esophageal manometry and pH testing.

72. Weak Peristalsis with Large Peristaltic Defects
1. Normal mean IRP (normal EGJ relaxation)
2. > 20% of swallows with large (> 5 cm) breaks in the 20 mmHg isobaric contour.
Normal

73. Case #4
Ambulatory reflux monitoring revealed an 12% incidence of acid reflux despite compliance with PPI therapy with an elevated DeMeester score.
The patient underwent Toupet fundoplication. Her symptom of heartburn has resolved and she is now off PPI therapy.
Her only concern post-operatively bloating and an inability to belch.

74. Know where to find resources to further your understanding of manometry

75. Further Education
If you are interested in further education consider reading the following text.
American Neurogastroenterology and Motility Society.

76. References
Conklin, J., Pimentel, M., Soffer, E. Color Atlas of High Resolution Manometry. Springer (2009)
Kahrilas, Peter J. et al. Esophageal Motility Disorders in Terms of Pressure Topography. J Clin Gastroenterol 2008;42:
Lin, Henry C. High Resolution Esophageal Manometry. Core Curriculum Conference, The University of New Mexico , 2011.

77. Western Montana Clinic
Thank You
Contact Information: Kevin Kolendich, MD
Western Montana Clinic
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