What are the indications for manometry (manometric testing)?

Manometry Indications

Esophageal manometry is definitively indicated for three primary clinical scenarios: evaluating unexplained dysphagia when mechanical obstruction has been excluded (particularly to diagnose achalasia), positioning pH probes relative to the lower esophageal sphincter, and preoperative assessment before antireflux surgery when alternative diagnoses like achalasia need to be excluded. 1

Clear Indications for Manometry

Unexplained Dysphagia

• Manometry is indicated to establish the diagnosis of dysphagia when mechanical obstruction (such as stricture) cannot be found on endoscopy or barium studies. 1
• This is particularly critical when achalasia is suspected, as manometry is the gold standard for diagnosing this condition. 1, 2
• Important caveat: More common esophageal disorders should be excluded first with barium radiographs or endoscopy before proceeding to manometry, given the low prevalence of achalasia. 1
• Manometry yields the highest diagnostic value in dysphagia patients, with approximately 79% showing abnormalities, compared to other indications. 3, 4

Device Placement

• Manometry is indicated for proper placement of intraluminal devices (such as pH probes) when positioning depends on functional landmarks like the lower esophageal sphincter. 1

Preoperative Assessment for Antireflux Surgery

• Manometry is indicated before antireflux surgery if there is any question of an alternative diagnosis, especially achalasia. 1
• Missing achalasia preoperatively can lead to catastrophic outcomes if fundoplication is performed, making this indication critical for patient safety. 1

Possible Indications (Use Clinical Judgment)

Routine Preoperative Peristaltic Assessment

• Manometry is possibly indicated for preoperative assessment of peristaltic function in all patients being considered for antireflux surgery, though this is not an absolute requirement. 1

Post-Surgical Dysphagia

• Manometry is possibly indicated to assess dysphagia symptoms in patients who have undergone either antireflux surgery or treatment for achalasia. 1

When Manometry is NOT Indicated

GERD Diagnosis

• Manometry is not indicated for making or confirming a suspected diagnosis of gastroesophageal reflux disease. 1
• Manometry does not measure reflux; it only assesses motor function. 1
• However, manometry may be useful in GERD patients prior to antireflux surgery or when treatment fails, to exclude alternative diagnoses and identify motor dysfunction. 5

Initial Evaluation of Chest Pain

• Manometry should not be routinely used as the initial test for chest pain or other esophageal symptoms because of low specificity and low likelihood of detecting clinically significant motility disorders. 1
• In chest pain patients, only 59% show abnormalities on manometry, and many findings are not clinically relevant. 3

Clinical Algorithm for Appropriate Use

For Dysphagia Patients:

1. First: Perform endoscopy with biopsies to exclude structural abnormalities, malignancy, and eosinophilic esophagitis (obtain at least 5 esophageal biopsies). 6
2. Second: Consider barium esophagram to evaluate for structural abnormalities and provide initial assessment of motility. 7
3. Third: Proceed to manometry if structural causes are excluded and functional disorder is suspected, particularly achalasia. 1, 7

For Chest Pain Patients:

1. First: Rule out cardiac causes completely, as the morbidity and mortality of ischemic heart disease substantially exceeds that of esophageal disorders. 8
2. Second: Perform endoscopy with esophageal biopsies to exclude eosinophilic esophagitis and other structural pathology. 8
3. Third: Trial empiric twice-daily PPI therapy for 4 weeks before considering manometry. 8
4. Fourth: Consider pH or impedance-pH monitoring if PPI therapy fails. 8
5. Manometry should only be considered if alternative diagnoses remain under consideration after these steps. 1

Common Pitfalls to Avoid

• Ordering manometry as the first test for dysphagia: Always exclude structural abnormalities with endoscopy and/or barium studies first. 1, 6
• Using manometry to diagnose GERD: This is inappropriate; use pH monitoring instead. 1
• Proceeding to antireflux surgery without manometry when achalasia is a possibility: This can result in severe complications. 1
• Over-interpreting manometric findings in chest pain patients: Many manometric abnormalities have low clinical significance in this population. 1, 3