Comparison of Air-Coupled Balloon Esophageal and Anorectal Manometry Catheters with Solid-State Esophageal Manometry and Water-Perfused Anorectal Manometry Catheters

Clinical gastrointestinal manometry studies are currently performed with multilumen water-perfused polyvinyl or strain gauge sensor solid-state catheters. A disposable catheter incorporating air-filled balloons has been developed with performance characteristics suitable for esophageal and anorectal manometry studies. Our aim was to compare esophageal and anorectal pressure measurements using this newly developed catheter with measurements obtained using standard solid-state or water-perfused catheters. Measurements of resting LES pressure, esophageal contraction amplitudes, and anorectal rest and squeeze pressures were obtained in 10 healthy volunteers using a solid-state esophageal catheter, a water-perfused anorectal catheter, and air-filled balloon esophageal and anorectal catheters. Correlation coefficient analysis demonstrated that LES pressures, esophageal contraction amplitudes, and anorectal resting and squeeze pressures were not significantly among between the different catheters. We conclude that recently developed air-filled balloon esophageal and anorectal manometry catheters provide very similar measurements of LES, esophageal body, and anorectal sphincter pressures compared to presently used manometry catheters.     

The value of conventional manometry in the identification of normal esophageal manometry

In the last decade, high-resolution esophageal manometry (HREM) is the main device for the management of dysphagia replacing conventional manometry (CM). Conventional manometry still seems to have some space to diagnose major motility disorders and differentiate normal from abnormal esophageal motility. The long term outcomes of patients with normal CM were analyzed in our study.Participants (patients with dysphagia and normal CM) took a questionnaire via a phone call in February 2021. Impact Dysphagia Questionnaire (IDQ) was used as an assessment tool.Only 55% (83/151) the individuals with previous normal manometric findings were reached via telephone. The group who have completed the survey was representative of the cohort. 66.2% of the participants were female (P = .40). The mean age was 57.21, mean weight was 70.69 kg, mean height was 163.74 cm and mean body mass index was 26.41. More than 40% of patients were completely asymptomatic at follow up, reflected by an IDQ score of 0. Only 28 out of 83 (33.7%) patients reported significant symptoms as reflected by an IDQ score greater than or equal to 7. The rest of responders admitted as having moderate to mild symptoms.HREM is a valid technique with comparable precision to CM. HREM measurements differ considerably to CM. The identification of normal motor function in CM is not likely a positive prognostic indicator and must be interpreted precautiously.     

高分辨率测压法在食管动力检测中的临床应用

高分辨率测压（HRM）是近年来发展的一种新型的固态测压法。采用密集分布的压力传感器同步采集整个食管的压力数据,通过计算机软件转变为三维空间图像,更简单直观地分析结果。基于HRM的分析特点出现了一种新的食管动力障碍芝加哥分类方法。本文对HRM的原理、分析指标、常见食管动力障碍性疾病在HRM中的特点及HRM的优缺点进行了概述。     

Standards for oesophageal manometry A position statement from the Gruppo Italiano di Studio Motilità Apparato Digerente (GISMAD)

Manometry is an important tool in the diagnosis of oesophageal motility, disorders, but proper instruments and methods are needed to obtain useful clinical information. The authors reviewed the minimal technical requirements, operative aspects, which information the final report should contain as well as indications and contraindications of the text itself. Technical requirements: At least a three-channel, multiple-lumen catheter perfused with a pneumo-hydraulic capillary infusion system which ensures deltaP/deltaT>150-200 mmHg/sec.; data should be recorded at a sampling rate of > or =8 Hz to study the oesophageal body and lower oesophageal sphincter; lower oesophageal sphincter tonic (pressure) and phasic activity (relaxations) and oesophageal body amplitude and peristaltic activity should be recorded. The final report must contain the patient's details, the indication for the test and a manometric diagnosis. Indications for manometry: Dysphagia (after ruling out any organic pathology); non- cardiac chest pain (after ruling out any cardiopulmonary involvement); systemic collagenosis (to investigate oesophageal involvement); gastro-oesophageal reflux disease (if surgery is planned). Contraindications are limited to: pharyngeal or upper oesophageal obstructions, oesophageal bullous disorder, cardiac conditions in which vagal stimulation may not be tolerated, severe coagulopathy and patient non-compliance.     

Percutaneous transhepatic manometry of sphincter of Oddi

A nonoperative examination of the function of the sphincter of Oddi, involving percutaneous transhepatic manometry via the percutaneous transhepatic biliary drainage tract, was developed and clinically applied in 23 patients with biliary disease. Long-term recording of sphincter of Oddi motility, which was impossible using conventional intraoperative or endoscopic manometry, was made possible by means of this method and revealed various changes of sphincter of Oddi motility. The mean recording time was 131.33±9.77 min. The frequency of contractions of the sphincter of Oddi in basal fasting conditions varied from 0 to 13/min and high-frequency contractions (frequency 9.49±0.35/min, duration 5.77±0.54 min) were observed in 12 patients on a total of 19 occasions. In five patients, high-frequency contractions were observed twice during one session of continuous recording and the interval between burst contractions was 85.4±13.3 min. Long-term continuous recording is advantageous for the evaluation of the function of the sphincter of Oddi and short-term manometry may not be representative of overall sphincter of Oddi motility.     

Age and gender affect likely manometric diagnosis: Audit of a tertiary referral hospital clinical esophageal manometry service

Background and Aim:  Awareness of patient demographics, common diagnoses and associations between these may improve the use and interpretation of manometric investigations. The aim of the present study therefore was to determine whether age and/or gender affect manometric diagnosis in a clinical motility service.
Methods:  An audit of all 452 clinical manometry reports issued from December 2003 to July 2005 with respect to age, gender and diagnosis was carried out. Patients were divided by age (17–24 years n  = 14, 25–44 years n  = 87, 45–64 years n  = 216 and ≥65 years n  = 135), and gender and data compared using contingency tables.
Results:  Women were more commonly referred overall (59%) and in each age bracket except <25 years (64% male). Men were more likely to have 'hypotensive' motor problems P  = 0.01. With aging, normal motor function became less common ( P  = 0.013), with non-specific motor disorder, ineffective/hypotensive peristalsis and 'achalasia-like' conditions each more common (individual P  = NS). Increasing age showed a trend for increased spastic motor disorders ( P  = 0.06). Gender did not, however, influence whether motility was abnormal ( P  = 0.5), spastic ( P  = 0.7) or whether a non-specific motor disorder was present ( P  = 0.1). In the total cohort, the principal manometric diagnoses were: non-specific motor disorder 33%, normal motility 29%, low basal lower esophageal sphincter pressure 18%, hypotensive/ineffective peristalsis 10%, achalasia/achalasia-like 6%, diffuse esophageal spasm 3% and other 1%.
Conclusions:  Aging leads to increasing esophageal motor abnormalities. Men and women have similar rates of dysfunction, although 'low-pressure problems' were more common in men.     

Effect of acute and long-term oral tobacco use on oesophageal motility

BACKGROUND AND AIMS: Nicotine administration is known to decrease lower oesophageal sphincter (LOS) pressure. Although a few studies have assessed the effect of tobacco on the LOS, the effect of acute and long-term oral tobacco use on oesophageal motility is not known. The study was designed to investigate the effect of acute and long-term oral tobacco use on LOS and distal oesophageal motility. METHODS: Thirty-six healthy men (aged 18-65 years, median 34 years; 18 oral tobacco users, 18 non-tobacco users) underwent oesophageal manometry using a water-perfusion system. After baseline manometry, tobacco users were asked to keep 0.5 g tobacco in their mouth for 10 min; non-users of tobacco were kept in quiet surroundings for a similar period. Manometry was then repeated. RESULTS: The LOS basal pressures were similar in tobacco users and non-tobacco users (mean +/- SD 15.4 +/- 6.3 vs 13.4 +/- 5.3 mmHg). In the distal oesophageal body, the velocity (4.4 +/- 3.1 vs 4.9 +/- 2.6 cm/s), amplitude (92.7 +/- 38.3 vs 84.8 +/- 33.2 mmHg) and duration of contraction (2.1 +/- 0.7 vs 1.7 +/- 0.9 s) were similar in tobacco users and non-users. Acute tobacco use did not affect these parameters. The numbers of abnormal waves (triple peaks and non-transmitted contractions) were also similar in the two groups. CONCLUSION: Oral tobacco use does not appear to affect LOS pressures and distal oesophageal motility acutely or in the long term.     

食管测压在贲门失弛缓症诊治中的应用及评价

目的　研究贲门失弛缓症患者的食管压力变化。方法　对 35例贲门失弛缓症患者与 30位正常对照的食管测压数据进行对比分析。结果　贲门失弛缓症组食管体部均为同步蠕动波 ,91 4 % (32 / 35 )为低幅同步收缩波 ;食管下括约肌松弛率 (LESRR)为 (6 9 1± 16 3) % ,明显低于正常对照的 (96 0± 0 1) % (P <0 0 1) ;食管下括约肌压增加 ;食管上括约肌各项指标与正常对照组比较无明显差别。结论　贲门失弛缓症的食管压力以低幅同步收缩波和LESRR增高为特征性表现。     

溃疡性结肠炎患者肛门直肠动力学的研究

采用多导单囊肛门直肠功能测定仪检测21例溃疡性结肠炎（UC）患者的肛门直肠压力、直肠容量感知、疼痛阈值、耐受阈值等指标，并与12例健康人进行对照。结果：UC组活动期和 缓解期的直肠静息压、肛管括约肌静息压、最大缩窄压及肛管长度与对照组无显著性差异，但UC患者活动期的初始感觉阈值、疼痛阈值、排便阈值均低于正常对照组，而缓解期与正常对照组相比无统计学差异。认为UC患者肛门括约肌的功能是正常的，但活动期直肠粘膜对容量刺激的反应性增高。     

Evaluation of vector manometry for characterization of functional outcome after restorative proctocolectomy

AIM: The impact of 3-dimensional vector manometry (VM) for characterization of the functional outcome of restorative proctocolectomy (RP) was studied in 61 patients at a median of 86 months after RP for ulcerative colitis. METHODS: A 14-day continence diary was utilized to quantify continence, urgency, and the frequency of defecation. The clinical outcome data were correlated to the physiology parameters of VM and volumetry. RESULTS: VM parameters at rest correlated with postoperative continence but not substantially with stool frequency and urgency. High radial asymmetry was significantly correlated with the degree of incontinence (r = 0.333, p = 0.013). Resting pressures demonstrated a better correlation with the degree of incontinence when documented for the high-pressure zone (HPZ; portion of the sphincter with at least 50% of the maximum pressure; r = 0.301, p = 0.025) and when performed in the continuous pull-through technique. Stool frequency and urgency were better characterized by volumetry parameters like threshold volumes and pouch compliance. The specificity and sensitivity of the vector volume at rest of the HPZ for the prediction of incontinence was 63.6% and 59.1%, respectively. The corresponding values were 67% and 68%, respectively, for radial asymmetry at rest. Stool frequency and urgency were better characterized by volumetry parameters like threshold volumes and pouch compliance. CONCLUSION: A strong anal sphincter at rest and a consistent radial distribution of the sphincter pressure are the most reliable indicators of continence after RP obtained by VM, but their clinical usefulness is limited.     

Upper gastrointestinal motor activity in patients with slow-transit constipation

Recent evidence indicates that patients complaining of severe chronic idiopathic constipation may have motor abnormalities not limited to the colon. We studied by manometric means gastric and small bowel motility in a homogeneous group of patients with chronic idiopathic constipation ie, the slow transit type. Twenty-one patients were recruited for the study and compared to 33 healthy subjects. Manometric examination was carried out for about 5 hr fasting and 1 hr after a standard meal. Analysis of the manometric tracings revealed during fasting no abnormalities in number and configuration of migrating motor complex with respect to controls. However, in 70% of patients motor abnormalities were detected, represented by bursts of nonpropagated contractions and discrete clustered contractions. After feeding, the patient group displayed a significantly shorter antral motor response to the meal with respect to controls; moreover, intestinal bursts of nonpropagated contractions were found in 19% of patients, and 14% of them had an early return of the activity fronts. We conclude that patients with slow transit constipation frequently display motor abnormalities of the upper gut. These findings further strengthen the concept that this condition may represent a panenteric disorder.     

Evaluation of miniature manometric techniques for the measurement of esophageal body pressure waves

BACKGROUND AND AIMS: Perfused miniature manometric assemblies with lumina of 0.4-0.5 mm i.d. have been developed. Reduced luminal size offers the advantages of reduced assembly bulk and increased assembly complexity with greater numbers of lumina and lower manometric infusion volumes because of a slower perfusion rate. This study investigated the recording fidelity of miniature manometric assemblies in the measurement of esophageal peristalsis. METHODS: Four miniature manometric assemblies, each containing manometric lumina of either 0.4 or 0.5 mm i.d., were evaluated at 100 and 180 cm lengths. The fidelity of miniature manometric luminal recordings were evaluated in vivo during esophageal peristalsis by using a simultaneous comparison with the standard lumina and an intraluminal strain gauge. RESULTS: During esophageal peristalsis, miniature manometric lumina recorded the peak amplitude of pressure waves, with an accuracy at perfusion rates of 0.04 mL/min (0.4 mm, i.d.) and 0.15 mL/min (0.5 mm, i.d.). CONCLUSION: Miniature manometric assemblies of lengths that are practical for use in humans are suitable for recording esophageal peristalsis.     

Clinical predictors of achalasia

Limited access to esophageal manometry (EM) may delay identification and treatment of patients with achalasia. In order to assess predictors to fast‐track patients for manometric confirmation of achalasia, we compared the clinical, radiographic, and endoscopic characteristics of achalasia patients to patients with functional dysphagia without manometric features of achalasia (controls). Patients referred for esophageal manometry to assess functional dysphagia prospectively identified over a 12‐month period were asked to participate in this study. The Achalasia Symptom Questionnaire (ASQ), a structured 11‐question survey (score: 0–best, 67–worst), was completed by all consenting patients. ASQ scores, esophago‐gastro‐duodenoscopy and upper gastro‐intestinal (UGI) contrast study findings were compared between patents with subsequently confirmed achalasia and those in whom achalasia was excluded by EM. Univariate logistic regression identified predictors that were tested by multivariate logistic regression to generate the model. Of the 803 EM performed over this 12‐month period, 95 patients were referred specifically to assess functional dysphagia. Of these, 50 were confirmed to have achalasia, and 45 had dysphagia without manometric evidence for achalasia and hence comprised the control group. ASQ scores were higher in achalasia patients (37 ± 13 versus 23 ± 10). Endoscopy and/or contrast esophagogram reports were available in 92% achalasia patients and 80% controls. Significant predictors for achalasia identified on univariate logistic regression included ASQ score, abnormal findings on endoscopy, and contrast UGI study. Using multivariate logistic regression, we were able to accurately predict the probability of achalasia to be P where P = e^y/(1 + e^y) and y =?5.6 + (0.089 × ASQ) + (2.088 × EGD) + (3.083 × UGI), e = exponential constant 2.7182, esophagogastroduodenoscopy (EGD) and UGI = 0 if normal and 1 if abnormal. Dropping the predictor ASQ, the formula changes to y =?2.7 + (1.987 × EGD) + (2.861 × UGI). Using only noninvasive investigations (i.e. eliminating EGD), the formula changes to y =?4.9653 + (0.0951 × ASQ) + (3.4312 × UGI). The probability of achalasia can be calculated in patients with functional dysphagia based on clinical, endoscopic, and radiographic findings allowing for a prioritization of EM studies.     

Normal pharyngoesophageal motility

Upper esophageal manometry is technically problematic. Published normal values are, therefore, few and wide ranging, reflecting catheter and recording-system variables, while the reproducibility of measurements and the influence of food consistency have been little studied. In this investigation, 50 healthy volunteers were studied with (1) a 2.8-mm-diameter six-sensor catheter-mounted transducer assembly and (2) a 3.2×7.2-mm sleeve device linked to a computerized recorder with a pressure-sample rate of 32/sec. The study protocol included water, bread, and semisolid swallows. Upper esophageal sphincter (UES) tonic pressures measured with the catheter-mounted assembly were lower and more reproducible than pressures measured with the sleeve system. Compared with water, bread swallows showed greater pharnygeal and sphincter after-contraction pressures, while semisolid swallows had less complete sphincter relaxation. Duration of pharyngoesophageal contractions was greater with bread or semisolid than water. The observations have established normal values for measurements of UES function and, in addition, have shown that (1) catheter variables significantly influence the measurement of upper sphincter tonic pressure, (2) pressures recorded with the catheter-mounted transducer are most reproducible, and (3) pharyngoesophageal motility patterns vary significantly according to the substance swallowed.This study was supported by the Scottish Home and Health Department grant K/MRS/50/C922.     

慢性特发性便秘患者肛门直肠测压表现及西沙必利的疗效研究

目的研究慢性特发性便秘（CIC）患者肛门直肠动力及直肠对容量刺激感觉的变化，同时观察西沙必利对CIC的疗效及对上述指标的影响。方法用肛门直肠测压法检测30例CIC患者，服用西沙必利前后的直肠动力及直肠对容量刺激感觉的变化。20名健康者作对照。结果肛门直肠括约肌最大收缩压降低（P＜0．05），引起直肠肛门抑制性反射的最小松弛容量（MRV）增大（P＜0．05），直肠内部容量刺激的排便阈值及疼痛阈值均明显增加（P＜0．01）；西沙必利10mg每日3次治疗4周可显著改善CIC患者上述异常改变（P＜0．01），增加CIC患者排便次数（P＜0．01），治疗总有效率为46，67％。结论CIC患者存在肛门直肠动力及内脏感觉异常，西沙必利可改善上述异常表现，对约半数CIC患者具有良好疗效。     

The external anal sphincter

Anal manometry and anal electromyography (EMG) were performed in 45 patients to evaluate the external anal sphincter. Their symptoms were soiling (N=6), incontinence (N=10), and obstipation (N=10). Clinical diagnoses were previous anal surgery (N=16), rectal prolapse—partial, total, intussusception (N=16), puborectalis syndrome (N=4), neurologic disorders (N=3), and others (N=6). The relationship between the maximum squeeze pressure (MSP) measured with anal manometry and the maximum (voluntary) contraction pattern (MCP) and signs of denervation (DEN) measured with anal EMG were examined. The correlation coefficient between MSP and MCP was 0.55 (P<.001) and between MSP, and DEN 0.13 (NS). A normal MSP always showed a normal MCP, a normal MCP showed an abnormal MSP in 43 percent only. In conclusion, the clinical value of anal EMG seems limited. Assessment of an additional anal EMG seems indicated in incontinent patients with previous anal surgery with a low MSP to estimate muscle function, whenever anal surgery is considered. Anal EMG during straining can easily confirm the clinical diagnosis of puborectalis syndrome. Presented in part at the meeting of the Dutch Society of Gastroenterology, Noordwijkerhout, The Netherlands, October 2–3, 1987.     

肠易激综合征患者直肠肛门动力学研究

为了研究肠易激综合征患者肛门运动功能，我们测定了５０例ＩＢＳ患者在１１例正常人直肠肛门压力衣排便功能；发现：（１）直肠静息压，肛门括约肌静息压及其最大缩窄压在ＩＢＳ腹泻组，便秘组及正常对照组组均无显著差异。（２）肛管高压带长度在ＩＢＳ腹泻组及便秘组均显著高于正常对照组。（３）直肠壶腹部的感觉阈值，最大耐受量等，在ＩＢＳ腹泻组均显著低于正常对照组。（４）ＩＢＳ便秘组感觉阈值与正常对照组差异，但其最大     

Esophageal stimulation tests

Both pharmacological and mechanical stimulation tests are used to evaluate the motor function of the esophagus and its sphincters. The stimulation of the esophagus allows not only evaluation of basal motor parameters but gives also information about the capability of the organ to respond to defined stimuli. Pentagastrin and edrophonium have been used to stimulate the esophageal motor function mainly with the intension of revealing abnormal motility patterns. In the esophageal body, the administration of the compounds allows detection of motor abnormalities. In contrast to a pharmacological stimulation test, the response of the lower esophageal sphincter to mechanical stimulation with an increase in abdominal pressure-applied by leg raising or using an abdominal beltremains a controversials field. The conflict is due to the fact that some investigators postulate an atropine-sensitive or vagally mediated reflex, whereas others suggest a purely mechanical extrinsic compression of the intraabdominal portion of the esophagus. The latter explanation seems to be wrong due to the fact that during mechanical stimulation with intermittend abdominal compression the change in pressure in the LES exceeds the time of the mechanical stimulation. The results were obtained in healthy persons and in patients with different esophageal motility disorders. It was concluded, therefore, that an increase in abdominal pressure results in an adaptive pressure rise in the LES, which can be used to evaluate the lower esophageal sphincter in a more detailed and functional way. In the esophageal body abnormal motility patterns can be more distinctly provoked by inducing swallowing with a defined bolus. Wet swallows more frequently allow detection of esophageal motor dysfunction than dry swallows. The inflation of a balloon in the esophageal body is sometimes helpful in patients with noncardiac chest pain to correlate mechanical stress with esophageal related symptoms.     

Childhood constipation: finally something is moving!

Recent developments in the evaluation and treatment of childhood constipation are likely to influence the way we deal with pediatric defecation disorders in the near future. Innovations in both colonic and anorectal manometry are leading to novel insights into functional defecation disorders in children. Promising results have been achieved with innovative therapies such as electrical stimulation and new drugs with targets that differ from conventional pharmacological treatments. Also, new surgical approaches, guided by manometric findings, have led to improvement in patient outcome. Finally, utilization of non-pharmacological interventions such as fiber and probiotics has been a field of particular interest in recent years. The aim of this article is to provide an update on these and other novel diagnostic and therapeutic tools related to childhood constipation.     

Idiopathic megarectum in adults

Outlet obstruction is thought to be one of the major factors responsible for idiopathic constipation. However, outlet obstruction itself may be due to several mechanisms. Among these, the presence of a megarectum is a leading one. Pathophysiological studies in adult patients with idiopathic megarectum are scarce. We studied by manometric and defecographic means 15 adult subjects with idiopathic megarectum and severe chronic constipation. Twenty-five healthy volunteers of both sexes acted as controls. Manometric variables showed significant differences between patients and controls with respect to internal anal sphincter pressure (P=0.02), minimum relaxation volume (P<0.001), defecatory sensory threshold (P<0.001), mean rectal tolerable volume (P<0.001), and rectal compliance (P<0.001). An altered response to straining was observed in 46.6% of patients and in 12% of controls (P=0.04); the ability to expel a 50-ml balloon per anum was 13.3% in patients and 100% in controls (P<0.001). Although all patients opened the anorectal angle and had descent of the pelvic floor, thereby confirming an adequate expulsion effort, evacuation of contrast material appeared extremely difficult. In fact, no subject was able to expel more than 30% of the rectal contents during fluoroscopic screening. These results confirm previous hypotheses that idiopathic megarectum displays features of a neuropathic process as an underlying mechanism. Further studies are needed that also take into consideration the muscle tone component of the rectum in these patients.