Esophageal Manometry

Report
No financial disclosures
http://monkeyartawards.typepad.com/.a/6a00e5
5097ba24883401053619f88f970b-800wi
St. Patrick Hospital is a 213-bed hospital
with a level 2 trauma center. St. Patrick
currently has 1,400 employees and 266
physicians.

St. Patrick Hospital
Motility Team.
 Jenifer Alsbury, RN
 Tamara Keogh, RN
 Christi Brinda, RN

High volume motility
center.
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.
http://timothystotz.com/wp-content/uploads/2013/05/floweringstaircase-timothy-stotz.jpg
http://2.bp.blogspot.com/_BrhJY2UGYrE/S8zk98lUGOI/AAAAA
AAAADU/jWC4zHes7LY/s400/Farside+-+pull.jpg
http://weaponsman.com/wpcontent/uploads/2013/12/DogOpeningDoor.jpg

Describe normal esophageal anatomy.

Understand the difference between water
perfused manometry and solid state
esophageal manometry.

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.

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.
http://www.webmd.com/digestive-disorders/picture-of-the-esophagus

Upper Esophageal
Sphincter (UES)
 Cervical esophagus
 Cricopharyngeus
 Inferior pharyngeal
constrictor
http://classconnection.s3.amazonaws.com/231/flashcards/1157231/jpg/
pharyngeal-muscles1328499814983.jpg

Esophageal body
 The proximal 5% is
striated muscle.
 The middle 35%-40% is
mixed (transition zone).
 The distal 50%-60% is
entirely smooth muscle.
http://www.christinas-home-remedies.com/imagefiles/esophagus-anatomy.jpg

Muscular composition
 Outer layer (longitudinal).
 Inner layer (circular).
▪ more precisely helical muscle.
http://www.nature.com/gimo/contents/pt1/full/gimo6.html

Clinical Correlation:
 Presbyesophagus also
known as tertiary
contractions
http://upload.wikimedia.org/wikipedia/commons/f/ff/Korkenzie
her-%C3%96sophagus.jpg

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
http://www.nature.com/gimo/contents/pt1/images/gimo14-f1.jpg
Understand the difference between
water perfused manometry and
solid state esophageal manometry

Water Perfusion Manometry
(Conventional).
 Every 5 cm

Solid State Manometry
(High Resolution, 3D).
 Every 1 cm
http://www.upmc.com/patientsvisitors/education/PublishingImages/G
-L/EsophManometry-1.jpg

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.

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: http://www.sierrainst.com/manoscan360.html
Magenta end of color spectrum
(hot colors) = highest pressure.

Blue end of color spectrum
(cool colors) = lowest pressure.

CONVENTIONAL
MANOMETRY
HIGH RESOLUTION
MANOMETRY

Need to move catheter for LES in most
systems

Catheter stays in one position

Water-perfusion systems are
multicomponent and cumbersome

Solid state systems are relatively simple
and less cumbersome

Low fidelity

High fidelity

Waveforms only

Color contour

LES measurements complex; some use
sleeves, others need station pull-through
technique

No need for pull through: software creates
an electronic sleeve for LES determination

Hard to find hiatal hernias

Hiatal hernias are easily identified

Water-perfused catheters are stiff and
more uncomfortable

Solid state catheters are soft and more
comfortable

Tests take longer

Procedure takes less time

Large gaps between channels (5 cm)

Array of 36 channels straddle the entire
esophagus, sees the entire organ

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.

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.

How will the test feel?
 Typically, the test is not uncomfortable.
 Some patients may experience a gagging
sensation when the tube is being placed.

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).

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.
http://classconnection.s3.amazonaws.com/369/flashcards/14
14369/png/assess_patency_of_nostrils1333807384492.png

The nostril is numbed
with 2% lidocaine jelly
using a 6-inch cotton
tip applicator.

The manometric
catheter is lubricated
with 2% lidocaine.
http://jan.ucc.nau.edu/daa/woundproducts/curasolgel3.jpg

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/h9991890_001.jpg
http://www.bartleby.com/107/Images/large/image855.gif

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.
http://www.upmc.com/patientsvisitors/education/PublishingImages/G
-L/EsophManometry-1.jpg

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.
http://www.robertsewellmd.com/Portals/2/Motility%20HD.jpg
http://www.nature.com/ajg/journal/v105/n5/images/ajg2010165i1.gif

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

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.
OROPHARYNGEAL
ESOPHAGEAL

Have difficulty swallowing
several seconds after
initiating a swallow.
Localize symptoms to the
cervical region.

Frequently associated with
coughing, choking, nasal
regurgitation, and
dysphonia.
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.

Have difficulty initiating a
swallow.



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?

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

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.
http://endoscopycenterofdelaware.com/assets/uploa
ded/images/all/UpperEndoscopy.jpg

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.
http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_i
mages/media/medical/hw/h9991108.jpg

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.
http://gastrocure.com/images/Esophageal_Manometry_img
_6.jpg

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.
1. Mean IRP > upper limits of normal (incomplete LES relaxation)
2. Absence of esophageal peristalsis (note: specifics vary for
type I, II, and III achalasia)
Normal

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)

An esophageal source of chest pain should be
considered only after cardiopulmonary
factors have been carefully investigated.
http://www.merckmanuals.com/professional/multimedia/v891242.html
?Ref=t&RefId=gastrointestinal_disorders/esophageal_and_swallowing_
disorders/gastroesophageal_reflux_disease_gerd&Plugin=WMP&Speed
=256&ItemId=v891242
http://drsvenkatesan.wordpress.com/tag/plaque-vs-thrombus/

A patient should first
undergo an upper
endoscopy and exclusion
of GERD.

GERD is the most
common cause of noncardiac chest pain.

GERD is much more
common than an
esophageal motility
disorder.
http://trustinfood.org/chest-pain/wpcontent/uploads/2012/10/Chest-Pain-After-Eating.jpg

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.
1. DCI > 8,000 mmHg-cm-s (hypercontractile esophagus)
2. Normal mean IRP (the EGJ relaxes normally)

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

The most important role
of esophageal manometry
in patients with GERD has
traditionally been for
evaluation prior to
antireflux surgery.
http://en.wikipedia.org/wiki/Nissen_fundoplication
Why is esophageal manometry done prior to
esophageal or gastric surgery?

Manometry may lead
to a modification of
the surgical approach.
www.wehealny.org

Esopahgeal manometry
may lead to an
alternative diagnosis
such as scleroderma or
achalasia.
http://www.nature.com/gimo/contents/pt1/images/gimo
20-f4.jpg

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.

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 preoperative esophageal manometry and pH
testing.
1. DCI > 8,000 mmHg-cm-s (hypercontractile
esophagus)
2. Normal mean IRP (the EGJ relaxes
normally)

The patient was treated for a
hypercontractile esophageal disorder with a
calcium channel blocker with a significant
reduction in symptoms.

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 preoperative esophageal manometry and pH
testing.
1. Normal mean IRP (normal EGJ relaxation)
2. > 20% of swallows with large (> 5 cm) breaks in the 20
mmHg isobaric contour.
Normal

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.

If you are interested in
further education
consider reading the
following text.

American
Neurogastroenterology
and Motility Society.
1.
2.
3.
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;42:627-635
Lin, Henry C. High Resolution Esophageal
Manometry. Core Curriculum Conference,
The University of New Mexico. 2008, 2011.
Contact Information:
Kevin Kolendich, MD
Western Montana Clinic
(406) 329-7169

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