What is the best study to assess esophageal motility disorders?

High Resolution Manometry is the Best Study to Assess Esophageal Motility Disorders

High resolution manometry (HRM) is the superior diagnostic test for assessing esophageal motility disorders due to its greater reproducibility, speed of performance, and ease of interpretation compared to standard manometry. 1

Advantages of High Resolution Manometry

• HRM provides more accurate measurement of bolus movement through the esophagus and can detect disorders of esophageal peristalsis and abnormalities of the lower esophageal sphincter (LOS) that may be missed with standard manometry 1
• HRM interpretation is significantly more accurate and faster, particularly when assessing esophageal aperistalsis, hypomotility, and relaxation of the LOS 1
• HRM enables classification of achalasia into subtypes (I, II, and III), which has prognostic value and can guide therapeutic decisions 1
• HRM results are highly reproducible for key parameters including upper esophageal sphincter function, pressure transition zone length, LOS length and pressure, and LOS relaxation 1

Clinical Applications of HRM

• HRM should be performed in patients with dysphagia after endoscopy with biopsies has ruled out mucosal and structural disorders 1
• HRM is essential before antireflux surgery to rule out LOS dysfunction (achalasia) and major motor disorders of the esophageal body 1
• HRM can provide useful diagnostic information in patients with dysphagia after antireflux surgery that cannot be obtained by standard manometry 1
• HRM is the preferred method to localize the LOS prior to catheter-based pH sensor placement 1

Enhanced Diagnostic Capabilities with Adjunctive Testing

• Adjunctive testing during HRM (larger volumes of water, solid/viscous swallows, or a test meal) can provide additional information and unmask pathology not seen with standard water swallows 1
• These adjunctive tests are more representative of normal swallowing behavior, more likely to induce symptoms, and improve diagnostic yield 1
• The addition of impedance to HRM (HRIM) can help visualize bolus movement and peristalsis effectiveness, though its clinical impact on therapeutic decision-making is still evolving 1

Diagnostic Accuracy and Clinical Impact

• HRM has demonstrated improved diagnostic yield for achalasia compared with conventional manometry 2
• In a randomized multicenter study, a manometric diagnosis was more frequently achieved with HRM than with conventional manometry (97% vs. 84%) 2
• HRM diagnoses tend to be more frequently confirmed during follow-up, suggesting that esophageal motility disorders can be identified earlier with HRM 2

Important Considerations

• Normal values for HRM are manufacturer and catheter specific, requiring appropriate reference ranges 1
• HRM diagnoses may change over time in some patients, which should be considered when planning interventions 3
• While HRM is superior diagnostically, patient tolerance may be slightly better with conventional manometry 2

Potential Pitfalls

• Failing to perform endoscopy with biopsies before manometry in patients with dysphagia to rule out mucosal and structural disorders 1
• Not using appropriate adjunctive testing (solid swallows, test meals) which can unmask pathology not seen with standard water swallows 1
• Overlooking the need to check for electrolyte abnormalities (particularly magnesium and potassium) which can affect esophageal motility 4
• Not considering that HRM diagnoses may change over time, which could impact treatment decisions 3

HRM has established itself as the gold standard for evaluating esophageal motility disorders and should be the first-line diagnostic test when esophageal dysmotility is suspected after structural causes have been excluded.