1. Mary Ganley RN BSHA, CGRN April 13, 2011

2.  List indications and contraindications for manometry procedures involving esophagus, stomach, small bowel, sphincter of oddi and anal rectal.  Define what a normal swallow appears on the manometry and how abnormal appears.

3.  ESOPHAGEAL MANOMETRY Measures the pressure through out the regions of the esophagus, which include the upper esophageal sphincter (UES), the esophagus body, and the lower esophageal sphincter (LES).  INDICATIONS 1. Evaluation of dysphasic 2. Evaluation of non cardiac chest pain 3. Pre operative evaluation for anti reflux surgery 4. Evaluation of gastric reflux disease 5.Location of LES for PH monitor 6. Exclude GI tract diseases scleroderma and pseudo-obstruction 7. To exclude esophageal etiology anorexia

4.  Uncooperative patients  Patient with Cardiac instability  Recent gastric surgery  Recent administration of sedatives or narcotics COMPLICATIONS  Rare aspiration

5.  A probe configured with pressure sensors  Transducer cables to transmit the electrical signals to amplifiers  Computer program to display waveforms Types of Catheters  Water profusion  Disposable air-filled probes  Solid state  High Resolution manometry  Impedance Manometry

6.  Equipment Set Up Calibrate per manufactures instructions Water to drink Topical Anesthetic 60CC Syringe Kleenex Basin

7.  Purpose of test  Positioning that will be used  Effective relaxation methods  Techniques to be used  Approximate length of procedure  Sensation patients are likely to experience  Risk of procedure and the importance of patient cooperating  Patient should be NPO at least 6 hours  Obtain history as to present symptoms  Medication withheld depends on the physicians

8.  Place the probe down the nasanpassage of patients choice  Pass quickly pass the gag refex  Give small sips of water  Pass to the depth of 60-65cm  Verify the distal sensors are in the stomach by having the patient take a deep breath. Increased pressure will be seen if the sensor is below the diaphragm.  Allow the patient to rest a few minutes after intubation

9.  Smooth muscle 3 to 5 cm in length  LES relaxes in response to swallowing  LES pressure, length, location and relaxation are evaluated.  The probe is pulled out 1cm at time  The LES pressure is usual10 to 45 mmHg  Six to 10 5cc of water given to patient and recorded  He probe is then pulled 5 cm above the LES  Ten swallows are given to measure esophageal muscle response

10.  Normal Swallow

11.  Abnormal findings  Swallows

12.  UES is striated muscle very high pressure and requires a soldd state catheter  Bernstein Test Used to asses esophageal sensitivity to acid. Normal saline and 0.1G HCL are alternately infused through the Bernstein port of the manometry probe. The discomfort experienced by the acid infusion must duplicate the typical symptoms for it to be considered positive

13.  Achalasia Difficulty swallowing Nocturnal regurgitation Pulmonary symptoms Manometry Symptoms Absent Peristalsis Incomplete LES relaxation Hypertensive LES  Distal Esophageal Spasms Simultaneous swallows Repetitive contraction Incomplete LES closure

14.  IEM – Ineffective Esophageal Motility Low contraction amplitude  Nutcracker Esophagus   Nutcracker esophagus is a disorder of the movement of the esophagus, and is one of many motility disorders of the esophagus, including achalasia and diffuse esophageal spasm. It causes difficulty swallowing, or dysphagia, to both solid and liquid foods, and can cause chest pain; it may also be asymptomatic. Nutcracker esophagus can affect people of any age, but is more common in the 6th and 7th decades of life. The diagnosis is made by an esophageal motility study (esophageal manometry), which evaluates the pressure of the esophagus at various points along its length. The term "nutcracker esophagus" comes from the finding of increased pressures during peristalsis, with a diagnosis made when pressures exceed 180 mmHg; this has been likened to the pressure of a mechanical nutcracker. The disorder does not progress, and is not associated with any complications; as a result, treatment of nutcracker esophagus targets control of symptoms only. Symptoms Nutcracker esophagus is characterized as a motility disorder of the esophagus, meaning that it is caused by abnormal movement, or peristalsis of the esophagus....

15.  Hypertensive LES  Scleroderma  Small Bowel Manometry  Sphincter of Oddie Manometry  Anal Manometry  Questions