What does a manometry report showing a weak Lower Esophageal Sphincter (LES) and ineffective, usually absent peristalsis mean for a patient with reflux symptoms?

Interpretation of Manometry Showing Weak LES and Ineffective/Absent Peristalsis in a Reflux Patient

The manometry findings of weak lower esophageal sphincter (LES) and ineffective, usually absent peristalsis indicate a significant esophageal motility disorder that is likely contributing to the patient's reflux symptoms and may impact treatment decisions, particularly regarding surgical management. 1

Clinical Significance of These Findings

Pathophysiological Meaning

• Weak LES: The lower esophageal sphincter serves as a barrier preventing stomach contents from refluxing into the esophagus. A weak LES means:

  • Reduced basal pressure of the sphincter
  • Compromised anti-reflux barrier
  • Increased likelihood of gastroesophageal reflux episodes 2, 3

• Ineffective/Absent Peristalsis: Normal peristalsis is essential for esophageal clearance of refluxed acid. Absent or ineffective peristalsis means:

  • Poor esophageal clearance function
  • Prolonged acid contact time with esophageal mucosa
  • Increased risk of mucosal injury 2, 4

Clinical Implications

1. Increased Reflux Burden:

   • Patients with ineffective esophageal motility (IEM) have higher acid exposure time and more reflux events compared to those with normal motility 5
   • The combination of weak LES and ineffective peristalsis creates a "double hit" - more reflux episodes and impaired clearance

2. Disease Severity:

   • These findings correlate with more severe GERD presentations
   • Higher risk of complications including esophagitis, strictures, and Barrett's esophagus 4, 3
   • More likely to experience respiratory symptoms of GERD 2

3. Treatment Considerations:

   • May have suboptimal response to standard acid suppression therapy alone
   • Prokinetic medications like metoclopramide may help by increasing LES tone and improving peristalsis 6
   • Important implications for surgical management decisions

Implications for Antireflux Surgery

The British Society of Gastroenterology guidelines emphasize that manometry should be performed in all patients being considered for antireflux surgery to rule out major motility disorders 1. The American Gastroenterological Association similarly indicates that manometry is indicated for preoperative assessment 1.

For this patient specifically:

• The findings of weak LES with ineffective/absent peristalsis represent a significant motility disorder
• This may influence the type of fundoplication if surgery is considered
• A complete 360° (Nissen) fundoplication might increase the risk of post-operative dysphagia in patients with poor esophageal motility
• A partial fundoplication might be more appropriate to avoid worsening dysphagia 1

Management Considerations

1. Medical therapy optimization:

   • Aggressive acid suppression with PPIs
   • Consider adding prokinetic agents like metoclopramide which can increase LES tone 6
   • Lifestyle modifications remain important (weight loss, avoiding late meals, head of bed elevation)

2. Surgical considerations:

   • If surgery is contemplated, these findings should guide the surgical approach
   • Partial rather than complete fundoplication may be preferred
   • The patient should be counseled about potential for post-operative dysphagia

3. Monitoring:

   • More vigilant endoscopic surveillance may be warranted due to increased risk of complications
   • Consider pH monitoring to assess adequacy of acid suppression therapy

Potential Reversible Causes

It's worth investigating if there are any reversible causes of esophageal dysmotility, such as:

• Hypothyroidism (which can cause esophageal aperistalsis that may be reversible with treatment) 7
• Certain medications that affect smooth muscle function
• Connective tissue disorders

The combination of weak LES and ineffective/absent peristalsis represents a significant motility disorder that likely explains the patient's reflux symptoms and may predict a more complicated disease course requiring careful management decisions.