What is the purpose and procedure of esophageal manometry?

Esophageal Manometry: Purpose and Procedure

Esophageal manometry is primarily indicated to establish the diagnosis of dysphagia when mechanical obstruction cannot be found, for placement of intraluminal devices, and for preoperative assessment before antireflux surgery. 1

Purpose of Esophageal Manometry

Esophageal manometry measures pressure changes within the esophagus to evaluate:

• Peristaltic contractions and sphincter function
• Contractility of the esophageal body
• Lower esophageal sphincter (LES) pressure and relaxation

Clear Indications for Manometry

1. Diagnosing dysphagia without obvious mechanical cause - particularly when achalasia is suspected 1
2. Accurate localization of the LES - for proper placement of pH monitoring devices 1
3. Preoperative assessment before antireflux surgery - to rule out alternative diagnoses, especially achalasia 1, 2

Possible Indications

• Assessment of peristaltic function before antireflux surgery 1
• Evaluation of dysphagia after antireflux surgery or achalasia treatment 1
• Diagnosis of rumination syndrome (with impedance) 1

Not Indicated For

• Making or confirming gastroesophageal reflux disease (GERD) diagnosis 1
• Initial testing for chest pain or other esophageal symptoms due to low specificity 1

Procedure of Esophageal Manometry

Types of Manometry

• Standard Manometry: Traditional method using pressure sensors
• High-Resolution Manometry (HRM): Superior technique with closer sensor spacing providing detailed pressure topography 1, 2
• HRM with Impedance: Combines pressure measurements with visualization of bolus movement 1, 2

Procedure Steps

1. Patient is typically fasted for 6-8 hours
2. A catheter with multiple pressure sensors is passed through the nose into the esophagus
3. The catheter is positioned to span from the pharynx to the stomach
4. Baseline measurements are taken of sphincter pressures
5. Patient performs a series of 10 wet swallows in supine or reclined position 3
6. Additional provocative maneuvers may be performed
7. Data is recorded and analyzed using specialized software

Clinical Utility

Esophageal manometry provides new diagnostic information in up to 87% of patients, changes diagnosis in 30%, and alters management in 44% of cases 4. This makes it a highly valuable diagnostic tool despite its specialized nature.

Important Considerations

• Proper Patient Selection: Manometry should not be the first-line test for esophageal symptoms. Endoscopy and/or barium studies should precede manometry to rule out structural abnormalities 1

• Achalasia Subtyping: HRM provides information on achalasia subtypes which helps predict clinical outcomes 1

• Technical Advances: HRM is superior to standard manometry in terms of reproducibility, speed, and ease of interpretation 1

• Clinical Symptoms vs. Manometry: Symptoms alone are not reliable enough to discriminate between specific esophageal motility disorders, highlighting the importance of objective testing 5

By providing objective measurements of esophageal function, manometry plays a crucial role in diagnosing motility disorders and guiding treatment decisions for patients with unexplained dysphagia, chest pain, and other esophageal symptoms.