9Once understood, manometry is so simple that anyone can do it
10What are the learning objectives from today’s lecture?
11Learning Objectives Describe normal esophageal anatomy. Understand the difference between water perfused manometry and solid state esophageal manometry.
12Learning ObjectivesBe able to properly identify and mark the following anatomic landmarks using high resolution manometry.The upper esophageal sphincter (UES)The esophageal bodyThe esophago-gastric junction (EGJ)Be able to describe patient preparation for esophageal manometry.
13Learning ObjectivesBe 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.
28Discuss the advantages high resolution manometry has over conventional esophageal manometry.
29High Resolution Manometry vs. Conventional Manometry Need to move catheter for LES in most systemsWater-perfusion systems are multicomponent and cumbersomeLow fidelityWaveforms onlyLES measurements complex; some use sleeves, others need station pull-through techniqueHard to find hiatal herniasWater-perfused catheters are stiff and more uncomfortableTests take longerLarge gaps between channels (5 cm)Catheter stays in one positionSolid state systems are relatively simple and less cumbersomeHigh fidelityColor contourNo need for pull through: software creates an electronic sleeve for LES determinationHiatal hernias are easily identifiedSolid state catheters are soft and more comfortableProcedure takes less timeArray of 36 channels straddle the entire esophagus, sees the entire organ
30High Resolution Manometry vs. Conventional Manometry
31Patient Preparation for High Resolution Esophageal Manometry
32Pre-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.
33Pre-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.
34Pre-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.
36Catheter PlacementBefore 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 jellyPertinent 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).
37Catheter 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.
38Catheter PlacementThe nostril is numbed with 2% lidocaine jelly using a 6-inch cotton tip applicator.The manometric catheter is lubricated with 2% lidocaine.
39Catheter 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.https://myhealth.alberta.ca/health/_layouts/healthwise/media/medical/hw/h _001.jpg
40Catheter PlacementThe 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.
41Catheter Placement5 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.
42Describe 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
46Indications 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
47DysphagiaThe 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.
48Dysphagia Have difficulty initiating a swallow. OropharyngealEsophagealHave 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.
49What are some the appropriate questions to ask a patient with dysphagia in the office?
50DysphagiaDo 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?
51Dysphagia Could you point to where you feel food is getting stuck? What medications are you using now?potassium chloridealendronateferrous sulfatequinidineascorbic acidtetracyclineaspirinNSAIDs
52Dysphagia 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.
53Dysphagia 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 diverticulumCricopharyngeal barStructural and functional assessment.Can assess the UES and pharynx more reliably than upper endoscopy.
54Dysphagia 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.
55Case #147 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.
56Achalasia - 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
57Case #1The patient underwent pneumatic dilation of her LES to 30 mm with marked improvement in her symptoms.Therapeutic optionsHeller myotomyPneumatic dilationBotox injection into the LESPOEM (Per Oral Endoscopic Myotomy)
58Chest PainAn esophageal source of chest pain should be considered only after cardiopulmonary factors have been carefully investigated.
59Chest PainA 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.
60Case #2A 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.
61Jackhammer EsophagusDCI > 8,000 mmHg-cm-s (hypercontractile esophagus)Normal mean IRP (the EGJ relaxes normally)
62Case #2He 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.TherapyRule out EGJ outflow obstruction causing reactive hypercontractile peristalsisTreat GERD if presentCalcium Channel blockers (Diltiazem)Nitrates (Isosorbide dinitrate)SildenafilBotox injection into the LES
63Prior to Anti-reflux Surgery The most important role of esophageal manometry in patients with GERD has traditionally been for evaluation prior to antireflux surgery.
64Prior to Anti-reflux Surgery Why is esophageal manometry done prior to esophageal or gastric surgery?
65Prior to Anti-reflux Surgery Manometry may lead to a modification of the surgical approach.
66Prior to Anti-reflux Surgery Esopahgeal manometry may lead to an alternative diagnosis such as scleroderma or achalasia.
67Prior 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.
68Case #342 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.
69Jackhammer EsophagusDCI > 8,000 mmHg-cm-s (hypercontractile esophagus)Normal mean IRP (the EGJ relaxes normally)
70Case #3The patient was treated for a hypercontractile esophageal disorder with a calcium channel blocker with a significant reduction in symptoms.
71Case #4A 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.
72Weak 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
73Case #4Ambulatory 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.
74Know where to find resources to further your understanding of manometry
75Further EducationIf you are interested in further education consider reading the following text.American Neurogastroenterology and Motility Society.
76ReferencesConklin, 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.