Audit of the role of oesophageal manometry in clinical practice.

This oesophageal laboratory serves a population of 1.5 million. The study aimed to review referral patterns and assess the cost effectiveness of oesophageal manometry in clinical practice. All 276 consecutive manometry studies performed between 1988 and 1991 were reviewed. Reasons for referral in the 268 first referrals were: dysphagia 50.4%, non-cardiac chest pain 23.1%, gastro-oesophageal reflux disease 14.2%, connective tissue disease 11.2%, and 'other' 1.1%. Manometry was normal in 49.3%, showed achalasia in 17.9%, diffuse oesophageal spasm in 13.4%, connective tissue disease in 7.8%, hypertensive lower oesophageal sphincter in 4.5%, nutcracker oesophagus in 2.6%, and 'other' in 4.5%. A positive diagnosis was significantly more common if dysphagia was the reason for referral (65.9% v 35.3%, p < 0.01). A positive diagnosis was established in 60% of patients referred with connective tissue disease, 30.6% with non-cardiac chest pain, and 21.1% with gastro-oesophageal reflux disease. A positive diagnosis was significantly more common in connective tissue disease when symptoms were present (85% v 10%, p < 0.05). Management was changed in 48.9% of all patients because of manometry findings. The cost of each oesophageal manometry study was calculated to be 63.00 pounds: every change in patient management cost 129.00 pounds. In conclusion, oesophageal manometry changed management in over 20% of patients with non-cardiac chest pain or gastro-oesophageal reflux disease and in over 60% of those with dysphagia. It is, therefore, a useful and cost effective test in patients with these symptoms.     

The changing use of esophageal manometry in clinical practice

Objective: Clinical practice guidelines now advise against the use of esophageal manometry in the early evaluation of unexplained chest pain. We examined data from patients referred for manometric evaluation over a 10-yr period (1987–1996) to see if clinicians were changing practice patterns and whether manometric diagnoses were affected by the changes.
Methods: Principal indications for the procedure and manometric findings were extracted from a review of 1162 subjects referred to a single clinical laboratory. The tracings were analyzed using a standardized classification method and categorized according to a pathophysiology-based scheme. Referral indications and manometric diagnoses were compared for the first and second 5-yr periods of study.
Results: Chest pain as a referral indication declined from the first to the second half of the study period (odds ratio, 0.44;   p < 0.0001  ), whereas dysphagia and preoperative evaluations became more common (odds ratio, 1.3;   p < 0.05  ; odds ratio, 13.7;   p < 0.0001  , respectively). Similarly, hypermotility disorders decreased in frequency (odds ratio, 0.63;   p = 0.0001  ), whereas hypomotility disorders increased (odds ratio, 1.6;   p < 0.01  ). The decrease in hypermotility disorders was solely related to a decrease in nonspecific spastic disorders, including nutcracker esophagus (odds ratio, 0.58;   p < 0.0001  ); the proportion of diagnoses of achalasia and diffuse esophageal spasm remained stable.
Conclusion: These data show that practice patterns are already following current guidelines. They also reflect the disillusionment of clinicians with the poor specificity of manometry in chest pain management, the increasing popularity of antireflux surgery, yet the ongoing observation that nonspecific spastic disorders are closely associated with unexplained chest pain and may have a still-undefined pathogenetic role.     

中国高分辨率食管测压临床操作指南(成人)

高分辨率食管测压(HREM)是诊断食管动力障碍疾病的金标准。准确的诊断建立在规范的操作之上。为了提高HREM的操作质量,中国医师协会消化医师分会胃食管反流病专业委员会牵头制定本指南。通过邀请国内相关领域专家对国内外有关文献进行检索、讨论,并召开2次专家研讨会,确定了指南的内容。本指南内容涉及HREM的适应证和禁忌证、详细的操作指导,以及结果阐述。     

Systematic comparison of conventional oesophageal manometry with oesophageal motility while eating bread.

Conventional oesophageal manometry is seldom accompanied by symptoms and may indeed be normal in patients with a history of dysphagia. We have recently shown that oesophageal manometry during eating may be helpful in the evaluation of patients with dysphagia but there has been little systematic comparison of fed oesophageal motor patterns with conventional clinical manometry. Oesophageal manometry in response to water swallows and during eating was therefore examined in 58 consecutive patients who had been referred for clinical oesophageal function studies. The patients were divided into three groups according to the percentage of peristaltic activity during conventional manometry: group 1 (n = 21) had 100% peristalsis; group 2 (n = 29) had 1-99% peristalsis and group 3 (n = 8) were aperistaltic. All the patients in group 3 had achalasia and remained aperistaltic during eating, however, was less than with water swallows in both group 1 (53% compared with 100%) and group 2 (49% compared with 82.3%) patients. Synchronous contractions and non-conducted swallows were correspondingly increased during eating. Although there was a significant correlation between the amplitude of peristaltic contractions with water and bread in groups 1 and 2, mean peristaltic amplitudes were less with bread than with water swallows. The data show that there are substantial differences in the distal oesophageal motility patterns produced by water swallows and by eating. Conventional manometry with water swallows does not allow prediction of the fed oesophageal motility pattern, except in patients with achalasia.     

Assessment of the rapid pullthrough technique in oesophageal manometry.

The lower oesophageal sphincter pressure was measured by infusion manometry using the rapid pullthrough technique in two studies designed to evaluate this technique. The first study performed was an assessment of its reproducibility in individual subjects on separate occasions. We conclude that the rapid pullthrough technique does not give reproducible results. The second study compared the lower oesophageal sphincter pressure obtained by this technique with that by the standard station pullthrough technique. We conclude that the results are not comparable.     

Evaluation of an air-filled microballoon and mini-transducer in the clinical practice of anorectal manometry

Anorectal manometry is becoming a commonly applied investigation in the field of colon and rectal surgery. Until now, however, most of this testing was performed in specialized units, which involved considerable expense and expertise to run. The authors assessed a commercially available mini-transducer and an air-filled microballoon catheter for their applicability to clinical anorectal manometry. This system is very accurate and is proving very useful in the ambulatory setting, on hospital wards, and in the operating room. It provides a simple alternative for areas where more sophisticated manometric systems are not available.Supported in part by a grant from Stryker Corporation, Kalamazoo, Michigan.     

Clinical evaluation of different fluid-filled systems for oesophageal manometry.

In a clinical study of oesophageal manometry with fluid-filled catheters, both a non-perfused system and a perfused system with a syringe pump have been compared to a system with a low-compliance perfusion pump, which served as a reference. Significantly lower values of motility amplitudes, motility derivatives, and partly of LES pressures, and a time delay of up to 0.5 sec of the amplitude maximum were obtained with the non-perfused system and the system with a syringe pump in comparison to the low-compliance system. Since the oesophageal function can be erroneously evaluated by use of a non-perfused system or a perfused system with a syringe pump, such systems cannot be recommended for clinical use.     

Role of stationary esophageal manometry in clinical practice. Manometric results in patients with gastroesophageal reflux, dysphagia or non-cardiac chest pain.

The present study was carried out to evaluate the diagnostic usefulness of stationary esophageal manometry in 263 patients divided into three groups: 150 patients with reflux symptoms, 68 with dysphagia, and 45 with non-cardiac chest pain. Patients with endoscopic abnormalities were excluded. Standard manometry was performed following the station pull-through technique. In the group of patients with reflux symptoms 40.7% had a normal manometry and 57.3% had abnormalities, being the most frequent (43%) hypotensive lower esophageal sphincter. In the dysphagia group, 20.6% of manometries were normal and 79.4% were abnormal, of which achalasia was the most frequent disorder (53.7%). In the case of non-cardiac chest pain, 42.2% of patients had a normal manometry and 57.8% an abnormal one, of which hypotensive lower esophageal sphincter was the most frequent abnormality. A significant higher proportion of manometric alterations were found in the dysphagia group compared to reflux symptoms and non-cardiac chest pain (p < 0.05). No statistical differences were found between the reflux and the non-cardiac chest pain groups. Manometry yields a higher diagnostic value in patients with dysphagia, and therefore manometry should be performed routinely after the exclusion of any organic esophageal disease. Manometry is not a first-choice functional diagnostic test in the study of patirnts with gastroesophageal reflux or non-cardiac chest pain.     

Comparison of intravenous edrophonium and oesophageal acid perfusion during oesophageal manometry in patients with non-cardiac chest pain.

Sixty consecutive patients referred for evaluation of non-cardiac chest pain had oesophageal manometry. Motility was assessed basally, after edrophonium 80 micrograms/kg iv and during oesophageal perfusion with 0.1 N HCl at 6 and 14 ml/min for eight and seven minutes respectively. A positive response, defined as symptom reproduction with or without abnormal motility, was present in 21 patients (35%) after acid perfusion and 12 (20%) after edrophonium. Eleven of the 12 patients responding to edrophonium also responded to acid perfusion, including most of the patients with primary motility disorders. Significantly greater increases in peristaltic duration, but not amplitude, were recorded after edrophonium (p less than 0.01) and acid perfusion (p less than 0.05) in positive responders, compared with non-responders. Results indicate that acid perfusion during oesophageal manometry may be a more useful stress test than edrophonium and that the mechanism of symptom production may be similar.