American Gastroenterological Association technical review on the clinical use of esophageal manometry

Topographic analysis of esophageal double-peaked waves

BACKGROUND & AIMS

Esophageal double-peaked waves occur with increased frequency in patients with functional esophageal symptoms. This study was undertaken to further understand the mechanisms responsible for their production.

METHODS

Topographic methods that consider temporal and spatial relationships of pressure data were used to examine 74 double-peaked waves detected in 18 subjects referred for manometric evaluation of unexplained symptoms. The studies were performed with a computerized data acquisition and analysis system designed for topographic plotting.

RESULTS

The second peak appeared to represent muscle contraction that merged with an unusually strong pressure site in the third topographic segment and covered 6.3 +/- 1.6 cm (33.5% +/- 8.5% esophageal length) proximal to this site. In 50 swallows (67.6%), the peak itself progressed in a retrograde direction at 13.2 +/- 10.8 cm/s, suggesting cephalad extension of a strong distal motor event. Analysis of wave onsets and movement of the peristaltic trailing edge detected retrograde propagation in up to 33.8% of waves, antegrade propagation in 2.7%, and simultaneous contraction in the remainder.

CONCLUSIONS

In symptomatic patients, the second peak in a double-peaked wave is typically a short, simultaneous, or retrograde pressure event in the region of and merging with the third topographic segment in the distal esophageal body. Topographic methods help explain the common association of these waveforms with other features of exaggerated contraction in the distal esophagus and suggest their relationship to inadequate inhibitory nerve function.

Standards for oesophageal manometry. A position statement from the Gruppo Italiano di Studio Motilità Apparato Digerente (GISMAD)

Manometry is an important tool in the diagnosis of oesophageal motility, disorders, but proper instruments and methods are needed to obtain useful clinical information. The authors reviewed the minimal technical requirements, operative aspects, which information the final report should contain as well as indications and contraindications of the text itself. Technical requirements: At least a three-channel, multiple-lumen catheter perfused with a pneumo-hydraulic capillary infusion system which ensures deltaP/deltaT>150-200 mmHg/sec.; data should be recorded at a sampling rate of > or =8 Hz to study the oesophageal body and lower oesophageal sphincter; lower oesophageal sphincter tonic (pressure) and phasic activity (relaxations) and oesophageal body amplitude and peristaltic activity should be recorded. The final report must contain the patient's details, the indication for the test and a manometric diagnosis. Indications for manometry: Dysphagia (after ruling out any organic pathology); non- cardiac chest pain (after ruling out any cardiopulmonary involvement); systemic collagenosis (to investigate oesophageal involvement); gastro-oesophageal reflux disease (if surgery is planned). Contraindications are limited to: pharyngeal or upper oesophageal obstructions, oesophageal bullous disorder, cardiac conditions in which vagal stimulation may not be tolerated, severe coagulopathy and patient non-compliance.

Diagnostic evaluation in gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) describes the clinical manifestations of reflux of gastric contents and the associated symptoms and patterns of tissue injury. Although its exact prevalence is difficult to determine, there is no doubt the GERD is the most common esophageal disease and probably among the most prevalent conditions seen in the primary care setting. GERD has a wide clinical spectrum, making the diagnostic evaluation challenging and complicated at times. Confirmatory test are rarely needed in patients with typical symptoms of heartburn or regurgitation who have a good clinical response to GERD therapy. This article describes the diagnostic tests necessary for some cases of GERD.

Normal esophageal function after myotomy in a patient with idiopathic diffuse esophageal spasm

A 52-year-old man with idiopathic diffuse esophageal spasm and hypertensive lower esophageal sphincter presented with dysphagia for several years. After unsuccessful therapy with forceful pneumatic dilation of the cardia, a myotomy of the cardia and distal esophagus was performed. The patient became asymptomatic, lower esophageal sphincter pressure diminished to less than 10 mm Hg, and esophageal body motor activity was normalized. This situation remains unchanged 6 years after the operation.

AGA technical review on treatment of patients with dysphagia caused by benign disorders of the distal esophagus

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the committee on September 27, 1998.

Deterioration of esophageal motility with age: a manometric study of 79 healthy subjects

OBJECTIVE

Data are limited on the effect of age on esophageal function. We evaluated whether aging influences the motor activity of the esophagus.

METHODS

Standard esophageal manometry was performed in 79 healthy, nonpaid volunteers of both sexes, 18-73 yr of age. Lower (LES) and upper esophageal sphincter (UES) characteristics and the properties of esophageal peristaltic waves were assessed by age groups: < or = 25 yr, 26-35 yr, 36-45 yr, 46-55 yr, 56-65 yr, and > 65 yr.

RESULTS

Age correlated inversely with LES pressure and length, UES pressure and length, and peristaltic wave amplitude and velocity, and correlated directly with the proportion of simultaneous contractions. Age was inversely correlated with the upper limits of normality (95th percentiles) of LES pressure (r = -0.943, p = 0.005), UES pressure (r = -0.943, p = 0.005), middle and lower peristaltic wave amplitude (r = -0.947, p = 0.004, and r = -0.844, p = 0.035, respectively), upper/middle peristaltic progression speed (r = -0.943, p = 0.005), and the proportion of simultaneous contractions (r = 0.926, p = 0.008), but not with the lower normal limits (5th percentiles) of these variables. Gender did not affect esophageal motility variables. The 95th percentiles of LES pressure differed by 20 mm Hg, those of lower peristaltic amplitude by 82 mm Hg, and those of percent simultaneous contractions by a factor of 2, between the younger and the older age groups.

CONCLUSIONS

The results suggest that normal esophageal motility deteriorates with advancing age. Thus, age-related normality limits of esophageal pressures should be considered before establishing the manometric diagnosis of hypercontractile esophageal motility disorders.

Noncardiac Chest Pain of Esophageal Origin

Cardiac and musculoskeletal disease should be excluded before considering an esophageal etiology for chest pain. Acid reflux is a common cause of chest pain and should be identified and treated. A therapeutic trial should consist of a proton pump inhibitor (omeprazole 20 mg or lanzoprazole 30 mg) given one or two times per day for at least 6 to 8 weeks. An alternative is to use an ambulatory pH study to confirm reflux. Also, if the patient fails the initial treatment, reflux should be confirmed with pH testing before increasing the dose of proton pump inhibitor or considering combination or surgical therapy. Esophageal manometry should be considered in patients with chest pain and dysphagia. It is also reasonable to perform manometry before a pH study since manometric localization of the lower esophageal sphincter (LES) is needed to ensure accurate pH probe placement. Only after manometric confirmation of a spastic esophageal motility disorder should patients be treated for esophageal spasm. In these patients, it is reasonable to try a long-acting formulation of a calcium-channel blocker or nitrate. Patients with chest pain who have a negative cardiac evaluation and who do not have reflux may have an abnormality in esophageal or cardiac sensation. These patients should be treated with a trial of an antidepressant and considered for referral to a mental health practitioner. All medication trials should continue at least 6 to 8 weeks to avoid a placebo effect and to allow adequate time for a therapeutic response.

Development of a topographic analysis system for manometric studies in the gastrointestinal tract

BACKGROUND

Intraluminal pressures from the gastrointestinal tract are conventionally analyzed from a set of two-dimensional tracings. We hypothesized that more information could be extracted by considering spatial relationships of pressure data.

METHODS

A system was developed for recording pressure from up to 21 sites and analyzing the results using two- and three-dimensional plotting methods connecting data in space as well as time. Esophageal pressures were measured in 10 volunteers. Data were displayed as three-dimensional contour plots, surface plots, or animated transformations of the pressure wave as it traveled axially in the direction of bolus movement.

RESULTS

Subjects tolerated catheter placement, and all analysis methods (conventional and topographic) were successfully completed in each case. At least 80% of the esophageal body and one sphincter could be sampled with the catheter in either a proximal or distal recording position.

CONCLUSIONS

A topographic analysis system is available for studying time and space relationships of pressure data. These novel techniques have the potential to provide greater insight into normal and abnormal gastrointestinal motor function than conventional manometric methods.

Measurement of gastrointestinal motility in the GI laboratory

Current tests of gastric and small intestinal motor function provide relevant physiological information, but their clinical utility is controversial. This article reviews the current procedures, indications, significance, pitfalls, and guidelines for gastrointestinal motility measurements by scintigraphy, gastroduodenojejunal manometry, and surface electrogastrography in humans. Methods included review of literature and discussions in closed and open fora among investigators, including presentations for peer review at focused (Iowa City American Motility Society Symposium, December 1995) and national meetings (American Gastroenterological Association, May 1996, and American Motility Society, September 1996). The current tests are generally complementary; scintigraphy is typically the first test in the evaluation of gastric motor function and often confirms the clinical suspicion of dysmotility. Manometry identifies patterns suggestive of myopathy, neuropathy, or obstruction but may be most helpful when it shows entirely normal findings, because manometry helps in part to exclude dysmotility as a cause of symptoms. Electrogastrography may identify dysrhythmias or failure of signal power to increase postprandially; rhythm abnormalities may be independent of impaired emptying among dyspeptic patients. The best validated and clinically most significant results pertain to transit tests; manometry may contribute importantly to the diagnostic process; and the significance of electrogastrography remains to be fully elucidated.

Outcome of patients operated on for esophageal atresia: 30 years' experience

PURPOSE

The aim of this study was to evaluate the outcome and late sequelae of patients with esophageal atresia or tracheoesophageal fistula.

METHODS

Sixty patients with esophageal atresia or tracheoesophageal fistula (EA-TEF) were treated in Tampere University Hospital in the years 1963 through 1993. Long-term outcome was evaluated with a questionnaire, pulmonary and esophageal function test results, 24-hour pH level monitoring, tracheobronchoscopy findings, and esophagogastroscopy with biopsy sections and samples for bacterial cultures.

RESULTS

One third of the respondents reported having impaired quality of life because of respiratory infections, dyspnea, and difficulties in swallowing and coughing at night. Eighteen percent had gastroesophageal reflux (GER) symptoms. The rate of symptoms decreased with age. Impaired pulmonary function, GER, abnormal esophageal peristalsis, and transit time were registered. Tracheobronchoscopy showed tracheal narrowing and inflammation in one third; in histopathologic analysis, however, the rate of inflammation was more than doubled. Histologically, esophageal inflammation was found in 51%, Barrett's esophagus in 6%, and a Helicobacter pylori infection in 21% of cases. The severity of GER, esophageal peristaltic abnormality, tracheal inflammation, and impairment of pulmonary function seems to be alleviated with age.

CONCLUSIONS

Although the long-term outcome of EA-TEF patients seems to be favorable, respiratory and gastrointestinal symptoms as well as functional abnormalities remain frequent. Gastric metaplasia in the esophagus and the high rate of tracheal, esophageal, and gastric inflammation indicate a need for long-term follow-up.

Basic considerations in gastroesophageal reflux disease

The cause of foregut symptoms is often quite uncertain until a comprehensive evaluation has been performed. The critical elements of this evaluation include historic, radiographic, endoscopic, and physiologic data, and most importantly, the insight of a mature diagnostician. Patients who are not evaluated in a comprehensive way are at risk for serious postoperative problems; surgeons who perform interventions without appropriate diagnostic support may have to deal with these unhappy patients. In the long run, a complete workup provides the guidance for treatment and is cost-effective.

Spatial patterns of fasting and fed antropyloric pressure waves in humans

1. Gastric mechanics were investigated by categorizing the temporal and spatial patterning of pressure waves associated with individual gastric contractions. 2. In twelve healthy volunteers, intraluminal pressures were monitored from nine side hole recording points spaced at 1.5 cm intervals along the antrum, pylorus and duodenum. 3. Pressure wave sequences that occurred during phase II fasting contractions (n = 221) and after food (n = 778) were evaluated. 4. The most common pattern of pressure wave onset along the antrum was a variable combination of antegrade, synchronous and retrograde propagation between side hole pairs. This variable pattern accounted for 42% of sequences after food, and 34% during fasting (P < 0.05). Other common pressure wave sequence patterns were: purely antegrade-29% after food and 42% during fasting (P < 0.05); purely synchronous-23% fed and 17% fasting; and purely retrograde-6% fed and 8% fasting. The length of sequences was shorter after food (P < 0.05). Some sequences 'skipped' individual recording points. 5. The spatial patterning of gastric pressure wave sequences is diverse, and may explain the differing mechanical outcomes among individual gastric contractions. 6. Better understanding of gastric mechanics may be gained from temporally precise correlations of luminal flows and pressures and gastric wall motion during individual gastric contraction sequences.

Methods for assessing the effects of drugs on gastrointestinal function in patients and healthy volunteers

The gastrointestinal tract is a complex organ with many functions. Many diseases affect the way in which the gastrointestinal tract performs these functions. The pharmaceutical industry and academia are putting great effort into the development of treatments for these diseases. As a consequence, there is increasing pressure on the clinical pharmacologist and gastroenterologist to develop methods to measure the effects of drugs on the gastrointestinal tract. This article reviews the methods currently available to assess gastrointestinal function; in particular it focuses on motility and sensitivity.

Oesophageal function testing and antireflux surgery

Despite the increasing emphasis that is placed on both pH measurement and oesophageal manometry, there is little consensus about their usefulness in the clinical setting. These tests are far from infallible and it is difficult to support their universal application in patients with gastrooesophageal reflux disease. Nevertheless, these imperfect tests are useful in certain situations and clinicians must strive to use them intelligently for those most likely to benefit.

Esophageal motility and reflux testing. State-of-the-art and clinical role in the twenty-first century

Esophageal function testing has an important place in the investigation of a significant proportion of patients with esophageal disorders. Appropriate application of these tests requires a proper understanding of their capabilities and limitations and careful primary assessment by other modalities. Esophageal manometry is most useful for assessing significant troublesome dysphagia in the absence of organic obstruction. Esophageal pH monitoring is an important adjunct to clinical assessment and endoscopy in the diagnosis of reflux disease. Although it is the gold standard for the measurement of esophageal acid exposure and assessment of the relationship of symptoms to reflux, there are weakness in both of these functions that should be understood when applying the test to the diagnosis of reflux disease.