Prospective evaluation of esophageal motor dysfunction in Down''s syndrome

OBJECTIVE: The aim of this study was to determine the prevalence and way of presentation of esophageal motor dysfunction in a nonselected population of subjects with Down's syndrome. METHODS: The study was conducted in 58 Down's syndrome patients and 38 healthy controls. A global symptom score and individual scores for dysphagia for liquids and solids, heartburn, vomiting/regurgitation, and chest pain were obtained. Esophageal function was evaluated initially by scintigraphy using liquid and semisolid bolus. Time-activity curves based on the mean condensed images were used to calculate residual activity at 100 s after swallowing. According to both scintigraphy and clinical evaluation results, participants underwent a radiological and manometric study. RESULTS: The most frequent symptoms in Down's syndrome patients were: dysphagia for liquids (n = 9), dysphagia for solids (n = 10), vomiting/regurgitation (n = 8), and chest pain (n = 2). Liquid and semisolid retention of the tracer was significantly higher in Down's syndrome patients than in controls (p < 0.05). In 15 participants with Down's syndrome, tracer retention was higher than the 95 percentile of controls' retention. No correlation was found between the global or individual symptom score and esophageal retention quantified by scintigraphy. Hypothyroidism was unrelated to esophageal symptoms or retention. Five of the 15 esophagograms performed were abnormal, showing barium retention and/or esophageal dilation. Manometry showed achalasia in two subjects, total body aperistalsis in one, and nonspecific esophageal motor disorder in two. CONCLUSION: Esophageal motor disorders, particularly achalasia, are frequent in individuals with Down's syndrome. Awareness of esophageal dysmotility in this population is important, even though symptoms are not evident, to avoid potential complications.     

Predictive Value of Symptom Profiles in Patients with Suspected Oesophageal Dysmotility

Bak Y-T. Lorang M. Evans PR. Kellow JE, Jones MP, Smith RC. Predictive value of symptom profiles in patients with suspected oesophageal dysmotility. Scand J Gastroenterol 1994;29:392-397.

The main aim of the study was to determine prospectively, in patients referred for oesophageal manometry, whether certain combinations of oesophageal symptoms are more likely than others to predict the presence of oesophageal dysmotility or a positive response to acid perfusion testing. In 524 consecutive patients, presenting predominantly with (non-cardiac) chest pain (n = 277), dysphagia (n = 186), or heartburn (n = 61), a standardized symptom assessment was completed before oesophageal manometry and acid perfusion testing. Half the patients in each group reported additional (‘secondary’) oesophageal symptoms as well as the predominant symptom. Oesophageal dysmotility was categorized in accordance with standard manometric criteria for achalasia, diffuse oesophageal spasm, nutcracker oesophagus, hypertensive lower oesophageal sphincter, or non-specific oesophageal motility disorder. In the predominant chest pain group, the prevalence of abnormal manometry was 33%; in the presence of secondary symptoms, especially dysphagia rather than heartburn, however, the prevalence was significantly (p < 0.01) increased. Also in the predominant chest pain group the prevalence of positive acid perfusion testing (44%) was significantly greater (p<0.05) in those with than in those without secondary symptoms. In the predominant dysphagia group, the prevalence of abnormal manometry was higher than in the other two groups (56%; p < 0.001) but was not affected by the presence or absence of secondary symptoms; this latter finding was also true for the predominant heartburn group. The distribution of specific manometric disorders in any group was not related to the presence or type of secondary symptoms, although a combination of dysphagia and chest pain discriminated achalasia from other manometric disorders. Additional oesophageal symptoms can thus be useful in predicting the results of oesophageal function testing in patients presenting with non-cardiac chest pain but not in patients presenting with predominant non-obstructive dysphagia.     

Is esophageal dysphagia in the extreme elderly (≥80 years) different to dysphagia younger adults? A clinical motility service audit

SUMMARY. Dysphagia in elderly patients has major effects on nutrition and quality of life. Although aging itself is associated with changes in esophageal motility, the impact of this on symptoms such as dysphagia is unclear. Data in the extreme elderly are also limited. Symptoms and manometric diagnoses from 23 consecutive older patients (older dysphagia [OD]) ≥80 reporting esophageal dysphagia (12 female, mean age 83 (range 80–93) were compared with those from 23 gender matched younger patients (young dysphagia [YD]) also with dysphagia (mean age 35, range [17–46]). More older patients reported dysphagia as their primary symptom (OD 22/23 vs YD 14/23, P = 0.005). Overall, dysphagia was most common for solids only (OD 16/23 vs YD 15/23) and rare for liquids only (OD 1/23 vs YD 3/23). Dysphagia for both liquids and solids was more frequent in older patients (OD 6/23 vs YD 1/23, P < 0.05). Fewer older patients reported heartburn (OD 3/23 vs YD 14/23, P = 0.001). Manometric diagnoses were generally similar between OD and YD patients with the most common diagnoses being ‘nonspecific esophageal motility disorder’ (nine each) and ‘ineffective peristalsis’ (OD = 6, YD = 7). There was a trend for diagnoses related to lower esophageal sphincter failure to be more frequent in younger subjects (OD 1 vs YD 7, P = 0.053). Despite differences in symptom patterns, broad manometric diagnoses in the extreme elderly with dysphagia are similar to younger dysphagia patients. Further studies are required to determine whether this relates to insensitivity in recording or reporting of esophageal manometry (or perceptual differences associated with aging).     

胃食管反流病相关非心源性胸痛患者食道患病率调查研究

ObjectiveTo investigate the prevalence and clinical characteristics of esophagus in patients with non-cardiac chest pain (NCCP). MethodsPatients who diagnosed with NCCP from January 2018 to April 2019 in Xinjiang Uygur Autonomous Region People's Hospital were selected as the study subjects. Detailed medical history, physical examination, upper gastrointestinal endoscopy, high resolution esophageal manometry and 24 h dynamic esophageal pH monitoring were performed on all subjects. ResultsThe total number of subjects was 85, of which male 45(52.94%), with an average age of 41.2±12.4 years;female was 40 (47.06%), with an average age of 43.3±10.9 years. The most common symptoms in NCCP patients were acid reflux 43.53%, dysphagia 31.76%, heartburn 24.71%. Endoscopic abnormalities of upper gastrointestinal tract accounted for 31.76%, esophageal manometry abnormalities accounted for 67.06%, and dynamic pH monitoring abnormalities accounted for 34.76%. The prevalence of GERD was 42.36% determined by upper gastrointestinal endoscopy combined with 24 h pH monitoring. According to manometric results, ineffective esophageal motility in 23.53% of NCCP patients was the most common cause of NCCP. ConclusionBy analyzing the causes of esophagogenous NCCP, it is helpful for clinicians to exclude other high-risk factors leading to chest pain and to provide appropriate treatment for their diagnosis and treatment     

Nutcracker esophagus: clinical evaluation of 97 patients]

Nutcracker esophagus is a manometric abnormality classified as a primary esophageal motor disorder, characterized by high pressure peristaltic waves in distal esophagus and related to non-cardiac chest pain. Further studies observed nutcracker esophagus in dysphagic patients and recently in gastroesophageal reflux disease. However, there is controversy about the meaning of this motor disorder and there are few clinical studies involving a great number of patients. A retrospective study involving 97 patients with manometric criteria of nutcracker esophagus according a control group was undertaken. Most of the patients were female (63.9%), mean age 54.3 years. The chief complaint was chest pain, followed by dysphagia and heartburn. Clinical findings, as a whole were chest pain (53.6%), dysphagia (52.6%), heartburn (52.6%), regurgitation (21.6%), otorhinolaryngologic symptoms (15.4%), dyspepsia (15.4%) and odynophagia (4.1%). The majority of patients had multiple symptoms, however in 28% just a single one was observed. Endoscopic examination observed erosive esophagitis in 8% of the patients, while signs of esophageal motor disorders were showed by esophagogram in 16.4%. Esophageal pH recordings indicated abnormal gastroesophageal reflux in 41.2% of the cases reported. We concluded that there are other symptoms in nutcracker esophagus patients besides chest pain and dysphagia and the use of esophageal pH recordings is helpful to establish its association with acid reflux and guide the appropriate therapy.     

Nutcracker esophagus: GERD or an esophageal motility disorder

A retrospective study was performed to determine the frequency of acid-related esophageal dysfunction in an unselected group of patients with nutcracker esophagus (NE). Five hundred seventy-two consecutive patients who underwent esophageal manometry and pH testing at one institution were evaluated. Forty-one percent were referred for evaluation of chest pain, 39% for reflux symptoms, and 20% for dysphagia, nausea, or epigastric pain. Esophageal manometry and 24-h pH monitoring were performed using standard methods. NE was defined as amplitude of phasic contractions of ≥180 mm Hg in any manometric tracing at any level of the esophagus. Abnormal total reflux was defined as >4% of the time with the esophageal pH < 4. A positive symptom index was defined as >50% of periods with pH < 4 coinciding with symptoms of chest pain or heartburn. Esophagitis was defined as an unequivocal mucosal defect if esophagogastroduodenoscopy was performed.
Forty-five patients met criteria for NE, with acid-related abnormalities found in 77%. Forty-nine percent had abnormal acid exposure time, 16% had positive symptom indexes with normal acid exposure, and 5% had endoscopic esophagitis. An additional 7% had only an increased number of reflux episodes with normal acid exposure and symptom indexes. The prevalence of NE was significantly higher in patients referred for chest pain than for typical reflux symptoms (14.3% vs 4.5%). Seventy-four percent of the patients with NE and chest pain did not have classic reflux symptoms. Seventy-six percent of 34 evaluable subjects who had been started on acid suppression were either improved or symptom free at an average of 10.7 months of follow-up.     

Esophageal motility disorders

Esophageal motility abnormalities are usually diagnosed when esophageal manometry is performed in patients with unexplained non-cardiac chest pain, non obstructive dysphagia or as a part of the preoperative evaluation for surgery of gastroesophageal reflux. Classification of these abnormalities has been a subject of controversy. These esophageal contraction abnormalities can be separated manometrically from the motor pattern seen in normal subjects, however, their clinical relevance is still unclear and debated. Many patients demonstrate motility abnormalities in the manometry laboratories, but may lack correlation with their presenting symptoms. Medical treatment can decrease symptoms particularly chest pain or acid reflux but there is no significant changes in the manometric patterns. Such motor abnormalities may not reflect a true disease state, but they could be markers of other abnormalities and they can modify the initial manometric findings in time.     

"Segmental Aperistalsis" of the Esophagus: A Cause of Chest Pain and Dysphagia

Although some patients with chest pain and dysphagia have manometric evidence of classic esophageal motor disorders, other patients with these symptoms may have only nonspecific findings of unknown importance. We describe five patients with chest pain and dysphagia in whom esophageal manometry showed a segment of esophagus with an increased frequency of simultaneous contractions associated with normal motility in the more proximal and distal esophagus. All patients had corresponding segmental abnormalities on video-esophagograms augmented with a solid holus; in four patients, the solid bolus caused reproduction of symptoms during the esophagography. We conclude that "segmental aperistalsis" may cause chest pain and dysphagia, and that the diagnosis may be made by careful manometric analysis of the entire esophagus, complemented by esophagography with a solid bolus.     

Diffuse esophageal spasm: has the term lost its relevance? Analysis of 217 cases

Diffuse esophageal spasm (DES) has been reported as a potential cause of dysphagia or chest pain; however, the patho‐physiology of DES is unclear. The aim of this study was to examine the manometric correlates of dysphagia and chest pain in this patient population. All patients undergoing manometry at our institution are entered into a prospectively maintained database. After institutional review board approval, the database was queried to identify patients meeting criteria for DES (≥20% simultaneous waves with greater than 30 mm Hg pressure in the distal esophagus). The patient‐reported symptoms and manometric data, along with the results of a 24‐hour pH study (if done), were extracted for further analysis. Out of 4923 patients, 240 (4.9%) met the manometric criteria for DES. Of these, 217 patients had complete manometry data along with at least one reported symptom. Of the patients with DES, 159 (73.3%) had dysphagia or chest pain as a reported symptom. Patients reporting either dysphagia or chest pain had significantly higher lower esophageal sphincter (LES) pressure than patients without these symptoms (P= 0.007). Significant association was noted between reported dysphagia and percentage of simultaneous waves. Chest pain did not correlate with percent of simultaneous waves, mean amplitude of peristalsis, or 24‐hour pH score. The origin of reported chest pain in patients with DES is not clear but may be related to higher LES pressure. Simultaneous waves were associated with reported dysphagia. Using current diagnostic criteria, the term DES has no clinical relevance.     

Ineffective oesophageal motility： Manometric subsets exhibit different symptom profiles

AIM： To compare the demographic and clinical features of different manometric subsets of ineffective oesophageal motility （IOM; defined as ≥ 30% wet swallows with distal contractile amplitude 〈 30 mmHg）, and to determine whether the prevalence of gastro-oesophageal reflux differs between IOM subsets.
METHODS： Clinical characteristics of manometric subsets were determined in 100 IOM patients （73 female, median age 58 years） and compared to those of 100 age-and gender-matched patient controls with oesophageal symptoms, but normal manometry. Supine oesophageal manometry was performed with an eight-channel DentSleeve water-perfused catheter, and an ambulatory pH study assessed gastrooesophageal reflux.
RESULTS： Patients in the IOM subset featuring a majority of low-amplitude simultaneous contractions （LASC） experienced less heartburn （prevalence 26%）, but more dysphagia （57%） than those in the IOM subset featuring low-amplitude propagated contractions （LAP; heartburn 70%, dysphagia 24%; both P ≤ 0.01）. LASC patients also experienced less heartburn and more dysphagia than patient controls （heartburn 68%, dysphagia 11%; both P 〈 0.001）. The prevalence of heartburn and dysphagia in IOM patients featuring a majority of non-transmitted sequences （NT） was 54% （P = 0.04 vs LASC） and 36% （P 〈 0.01 vs controls）, respectively. No differences in age and gender distribution, chest pain prevalence, acid exposure time （AET） and symptom/reflux association existed between IOM subsets, or between subsets and controls.
CONCLUSION： IOM patients with LASC exhibit a different symptom profile to those with LAP, but do not differ in gastro-oesophageal reflux prevalence. These findings raise the possibility of different pathophysiological mechanisms in IOM subsets, which warrants further investigation.     

The Nutcracker Esophagus: A Late Diagnostic Yield Notwithstanding Chest Pain and Dysphagia

The nutcracker esophagus, a primary motor disorder, is frequently associated with noncardiac chest pain. However, there are no data on whether its diagnosis, as in other esophageal motility disorders, is delayed. Since the disorder is frequently heralded by alarming symptoms such as chest pain and dysphagia, diagnosis should be made as soon as possible. In this study we assessed the diagnostic delay, if any, in patients with the nutcracker esophagus. Moreover, we were interested in whether the abnormalities described in the distal esophagus could also involve the entire viscus. Fifty-four subjects (age range 23–78 yr) with the nutcracker esophagus were assessed for clinical and manometric variables as an overall group and after dividing them into subgroups according to their symptoms. The manometric variables were compared with those obtained in 61 controls (age range 21–67 yr). Overall, a diagnosis of nutcracker esophagus was made after an average period of 36 ± 6 months, and surprisingly, this was not different in the various subgroups complaining of either chest pain, dysphagia, or both. Analysis of manometric variables showed that the mean amplitude of contractions was significantly higher in the patients' group at all esophageal body levels, even in the proximal portions. Again, there were no significant differences among the subgroups of nutcracker esophagus with respect to the symptoms. Notwithstanding the presence of alarming symptoms, such as chest pain and dysphagia, the nutcracker esophagus is diagnosed on average after 3 years from the onset of symptoms. Manometric assessment seems to confirm that this entity may indeed represent a primary esophageal motor disorder. The major dysfunction is due to an abnormal increase of contraction amplitude of the entire esophageal body.     

Esophageal testing of patients with noncardiac chest pain or dysphagia. Results of three years' experience with 1161 patients

Records from 910 patients referred to our clinical esophageal manometry laboratory for evaluation of noncardiac chest pain between January 1983 and December 1985 were reviewed and compared with records from 251 patients referred for dysphagia. Evaluation included baseline esophageal manometry, acid perfusion test, and edrophonium provocation. In the chest-pain group, 655 patients (72%) had normal esophageal motility and 255 (28%) had abnormal motility. Nutcracker esophagus was present in 48% of abnormal tracings, suggesting that it is a manometric marker for noncardiac chest pain. Of the total chest-pain group, 243 patients (27%) had their pain reproduced during provocative testing ("definite" esophageal pain); 192 patients (21%) had baseline manometric abnormalities but no pain during provocative testing ("probable" esophageal chest pain). The highest percentage of positive provocative responses (34%) occurred in patients with nutcracker esophagus on baseline manometry. Manometric abnormalities were statistically commoner (p less than 0.001) in patients with dysphagia, occurring in 53%. Achalasia (36%) and nonspecific esophageal motility disorders (38%) were the commonest abnormalities in this group, with nutcracker esophagus being infrequent (10%).     

Intraesophageal Balloon Distention versus Drug Provocation in the Evaluation of Noncardiac Chest Pain

Intraesophageal balloon distention (IEBD) has been advocated as an effective provocative test for the evaluation of chest pain and dysphagia. The normal esophageal response to intraesophageal balloon distention is to generate a sustained contraction proximal to the balloon while showing a distinctive absence of activity distal to the balloon. We evaluated intraesophageal balloon distention in 62 patients with noncardiac chest pain and compared the diagnostic results to those obtained by using a combination of acid infusion, edrophonium (80 micrograms/kg iv) and bethanechol (80 micrograms/kg sq). These 62 patients were also compared with 10 normal volunteers who underwent intraesophageal balloon distention. Abnormal distal manometric activity consistent with spasm and was seen in 38/62 (61%) patients. Distal manometric activity was not seen in any normal volunteer. Diagnostic results (symptom reproduction with manometric changes but without EKG changes) were seen in 26/62 (42%) patients, but in nine of the 62 (14%) patients with combined drug provocation (p less than 0.05). Intraesophageal balloon distention is superior to a combination of provocative drugs in evaluating noncardiac chest pain symptoms. The presence of abnormal manometric activity distal to the balloon may represent regulation of esophageal motility.     

Physiopathologic approach in esophageal motor disorders: from the diagnosis to therapeutic implications

Motor disorders are an important chapter in esophageal pathology; from a clinical point of view, these disorders are characterised by dysphagia, non-cardiac chest pain, pyrosis and regurgitation. It is important to underline that chest pain and dysphagia are not specific to motility disorders; in fact, they are also present in other pathologies like peptic or infective esophagitis. In order to attribute these symptoms to a functional cause, it is first of all is necessary to exclude an organic pathology; this can be done with the help of radiological and endoscopical examination when the symptoms are dysphagia, pyrosis and regurgitation, or with electrocardiography or angiography, when the symptom is chest pain. The functional pathology is marines studied by manometric and pH-metric techniques. The manometric technique represents an important instrument for diagnosing esophageal motor disease. The aim of this study, after a review of the literature, is to describe the principal esophageal motor disorders and the physiopathological approach, that have important implications in diagnosis and therapy.     

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.     

Classic and vigorous achalasia: a comparison of manometric, radiographic, and clinical findings

Compared with classic achalasia, vigorous achalasia has been defined as achalasia with relatively high esophageal contraction amplitudes, often with minimal esophageal dilation and prominent tertiary contractions on radiographs, and with the presence of chest pain. However, no study using current manometric techniques has compared manometric, radiographic, and clinical findings in vigorous and classic achalasia or questioned the usefulness of making this distinction. Fifty-four cases involving patients with achalasia whose radiographic and manometric studies were performed within 6 months of each other were available for review. Patients with vigorous achalasia (n = 17), defined by amplitude greater than or equal to 37 mm Hg, and patients with classic achalasia (n = 37), defined as amplitude less than 37 mm Hg, had substantial overlap in radiographic parameters of esophageal dilation, tortuosity, and tertiary contractions. Manometric properties of repetitive waves and lower esophageal sphincter pressure and clinical aspects of chest pain, dysphagia, heartburn, and satisfactory responses to pneumatic dilation were similar in both forms of achalasia. A separate analysis of patients with mean contraction amplitude greater than 60 mm Hg revealed similar findings. It is concluded that use of amplitude as a criterion for classifying achalasia is arbitrary and of dubious value.     

Functional esophageal disorders

Functional esophageal disorders represent processes accompanied by typical esophageal symptoms (heartburn, chest pain, dysphagia, globus) that are not explained by structural disorders, histopathology-based motor disturbances, or gastroesophageal reflux disease. Gastroesophageal reflux disease is the preferred diagnosis when reflux esophagitis or excessive esophageal acid exposure is present or when symptoms are closely related to acid reflux events or respond to antireflux therapy. A singular, well-defined pathogenetic mechanism is unavailable for any of these disorders; combinations of sensory and motor abnormalities involving both central and peripheral neural dysfunction have been invoked for some. Treatments remain empirical, although the efficacy of several interventions has been established in the case of functional chest pain. Management approaches that modulate central symptom perception or amplification often are required once local provoking factors (eg, noxious esophageal stimuli) have been eliminated. Future research directions include further determination of fundamental mechanisms responsible for symptoms, development of novel management strategies, and definition of the most cost-effective diagnostic and treatment approaches.     

Esophageal spasm: demographic, clinical, radiographic, and manometric features in 108 patients

Diffuse esophageal spasm (DES) remains insufficiently understood. Here we aimed to summarize the demographic, clinical, radiographic, and manometric features in a large cohort of patients with DES. We identified all consecutive patients diagnosed with DES from 2000 to 2006 at Mayo Clinic Florida. The computerized records of these patients were reviewed to extract relevant information. We performed 2654 esophageal motilities during that period. There were 108 patients with esophageal spasm, and 55% were female. Median age was 71 years. The most common leading symptom was dysphagia in 55, followed by chest pain in 31. Weight loss occurred in 28 patients. The median of time from onset of symptoms to diagnosis was 48 months (range 0-480), with a median of time from the first medical consultation to diagnosis of 8 months (range 0-300). The most frequent comorbidities were hypertension and psychiatric problems. At presentation, 81 patients were taking acid-reducing medications, and 49 patients were taking psychotropic drugs. An abnormal esophagogram was noted in 46 of 76 patients with this test available, but most radiographic findings were nonspecific with the typical 'corkscrew' appearance seen in only three patients. Gastroesophageal reflux disease (GERD) was diagnosed by pH testing or endoscopy in 41 patients. We did not find any difference between the rate of simultaneous contractions or esophageal amplitude between patients with a leading symptom of dysphagia and those with chest pain. DES is an uncommon motility disorder that often goes unrecognized for years. Physicians should be aware of the clinical heterogeneity of DES and consider motility testing early in the course of unexplained esophageal symptoms. Given the high prevalence of GERD in DES, the role of GERD and the impact of acid-reducing therapy in DES deserve further study.     

Esophageal manometry

Esophageal manometric study has gained tremendous popularity over the past decade. However, the contribution of this diagnostic technology has not been critically evaluated. The purpose of this report is, therefore, to determine how frequently esophageal manometry alters the clinical diagnosis and treatment and to assess the cost of new information. The patients reviewed in this report consisted of 363 consecutive referrals. Each completed a questionnaire, had an esophagogram, and underwent an esophageal manometric study for the evaluation of dysphagia, heartburn, and/or chest pain of unexplained etiology. To determine the clinical contribution of manometry, diagnoses before and after the study were compared. On the basis of symptoms and radiologic data, specific clinical entities were diagnosed in 36 patients. Manometric study did not confirm the diagnosis of achalasia in four of the 27 patients referred with this diagnosis and resulted in 19 additional specific diagnoses. Manometry changed the course of treatment in 14 cases, eight additional patients with achalasia received treatment, and four false-positive patients were spared inappropriate treatment. Moreover, two patients with simultaneous esophageal motor disorder and chest pain were spared further investigation. It is concluded that esophageal manometry altered the clinical diagnosis in 6% and changed the course of treatment in 4% of the population studied. Esophageal manometry is beneficial in patients with chest pain, dysphagia, and those in whom diagnosis of achalasia is suspected, but is of little benefit in patients with chronic heartburn. Assuming the cost per study to be $250, the cost of the study was $3945 per alteration of diagnosis and $6482 per alteration of treatment.