- •
High-resolution manometry (HRM) is an effective tool to study pathophysiologic motor events in gastroesophageal reflux disease (GERD).
- •
HRM has clinical utility in excluding esophageal outflow obstruction mimicking GERD.
- •
Preoperative esophageal HRM can alter surgical decisions and is of clinical value before antireflux surgery.
- •
Provocative testing during HRM may assess esophageal smooth muscle peristaltic reserve.
Esophageal Manometry in Gastroesophageal Reflux Disease
Section snippets
Key points
Advances in esophageal manometry
Manometry systems are designed to measure the timing and amplitude of pressure events in the esophagus and its sphincters via a linear array of pressure sensors on a catheter. Assimilation, integration, and display systems convert these pressure recordings into electrical signals that can be displayed as pressure waveforms or topographic pressure plots. The roots of HRM began in the mid-1970s when the first high-fidelity manometry system was developed by Jerry Dodds and Ron Arndorfer.3 This
Pathophysiologic correlates of GERD on HRM
By the Montreal definition, GERD develops when the reflux of stomach contents causes troublesome symptoms and/or complications.9 The disease is common worldwide and reduces the quality of life.10 Proton-pump inhibitors (PPIs) are the mainstay of GERD management, working by binding to the H+,K+-ATPase enzyme in the gastric parietal cell to decrease the production of gastric acid. Although this medication class is excellent at suppressing acid production, 30% to 40% of GERD patients continue to
HRM software tools and metrics
The most impactful HRM software tool is the electronic sleeve used in the assessment of LES postswallow residual pressures.1, 4 The area interrogated by this tool can be adjusted by the user to include the entire LES high-pressure zone, including the crural diaphragm when the 2 are in close proximity. IRP is the metric demonstrated to have the highest sensitivity in segregating normal from abnormal bolus flow across the LES-EGJ, using a threshold of 15 mm Hg.41 The IRP reports the nadir LES
Clinical application of HRM metrics
Although manometry cannot be used to diagnose GERD, HRM findings may be useful in identifying certain pathophysiologic correlates relevant to patient management. As manometry is used for identifying the proximal margin of the LES for placement of pH and pH-impedance catheters, HRM studies are easily available in GERD patients undergoing pH monitoring.48 Comparative interpretation can be performed in this setting, providing useful insights into esophageal motor patterns with and without abnormal
Provocative maneuvers
There has been recent interest in the incorporation of physiologic challenges during HRM to further refine the assessment of motility in GERD, particularly before antireflux surgery. Daum and colleagues62 postulated that the diagnostic yield of HRM could improve when HRM testing is performed under an increased esophageal workload. Patients with endoscopic evidence of GERD, patients with endoscopy-negative reflux symptoms, and controls underwent HRM in the upright, seated position while
Summary
HRM is an advance from standard manometry through the use of more closely spaced pressure sensors, allowing for more nuanced analysis of the esophagus and its sphincters as well as through more intuitive data displays in the form of Clouse plots. While a useful research tool for GERD in improving identification of TLESRs associated with reflux and determining deficits in EGJ barrier function contributing to reflux, HRM provides additional motor correlates for esophageal hypomotility and GERD.
References (67)
- et al.
Improved infusion system for intraluminal esophageal manometry
Gastroenterology
(1977) A new technique for continuous sphincter pressure measurement
Gastroenterology
(1976)- et al.
Transient lower esophageal sphincter relaxations and reflux: mechanistic analysis using concurrent fluoroscopy and high-resolution manometry
Gastroenterology
(2006) - et al.
A new era in esophageal diagnostics: the image-based paradigm of high resolution manometry
J Am Coll Surg
(2009) - et al.
High-resolution manometry studies are frequently imperfect but usually still interpretable
Clin Gastroenterol Hepatol
(2011) Making the most of imperfect high resolution manometry studies
Clin Gastroenterol Hepatol
(2011)- et al.
Preoperative diagnostic workup before antireflux surgery: an evidence and experience-based consensus of the esophageal diagnostic advisory panel
J Am Coll Surg
(2013) - et al.
The value of high resolution manometry in the assessment of the resting characteristics of the lower esophageal sphincter
J Gastrointest Surg
(2009) - et al.
Role of the lower esophageal sphincter on acid exposure revisited with high resolution manometry
J Am Coll Surg
(2011) - et al.
AGA technical review on the clinical use of esophageal manometry
Gastroenterology
(2005)
Abnormal sensory perception in patients with esophageal chest pain
Gastroenterology
Functional esophagogastric junction with intact peristalsis: a heterogenous syndrome sometimes akin to achalasia
J Gastrointest Surg
Unique features of esophagogastric junction pressure topography in hiatus hernia patients with dysphagia
Surgery
High resolution manometry in evaluation of factors responsible for fundoplication failure
J Am Coll Surg
Topographic esophageal manometry: an emerging clinical and investigative approach
Dig Dis
Learners favor high resolution esophageal manometry with better diagnostic accuracy over conventional line tracings
Gut
Evaluation of esophageal motor function in clinical practice
Neurogastroenterol Motil
High resolution manometry: the Ray Clouse legacy
Neurogastroenterol Motil
Value of preoperative esophageal function studies before laparoscopic antireflux surgery
Surg Endosc
Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography (EPT)
Neurogastroenterol Motil
The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus
Am J Gastroenterol
Epidemiology of gastro-oesophageal reflux disease: a systematic review
Gut
Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicenter study using combined ambulatory impedance-pH monitoring
Gut
Esophageal pH-impedance monitoring and symptom analysis in GERD: a study in patients off and on therapy
Am J Gastroenterol
Criteria for objective definition of transient lower esophageal sphincter relaxation
Am J Physiol
Objective definition and detection of transient lower esophageal relaxation revisited: is there room for improvement?
Gastroenterology
The gastro-oesophageal common cavity revisited
Neurogastroenterol Motil
Increased intragastric pressure gradients are involved in the occurrence of acid reflux in gastroesophageal reflux disease
Scand J Gastroenterol
Sleeve sensor versus high-resolution manometry for the detection of transient lower esophageal sphincter relaxations
Am J Physiol Gastrointest Liver Physiol
High resolution esophageal pressure topography is superior to conventional sleeve manometry for the detection of transient lower esophageal sphincter relaxations associated with a reflux event
Neurogastroenterol Motil
High resolution manometry to detect transient lower oesophageal sphincter relaxations: diagnostic accuracy compared with perfused-sleeve manometry, and the definition of new detection criteria
Aliment Pharmacol Ther
Ambulatory high resolution manometry, lower esophageal sphincter lift and transient lower esophageal sphincter relaxation
Neurogastroenterol Motil
Studies of acid exposure immediately above the gastro-oesophageal squamocolumnar junction: evidence of short segment reflux
Gut
Cited by (18)
Diagnosis and treatment of gastroesophageal reflux disease: recommendations of the Asociación Mexicana de Gastroenterología
2016, Revista de Gastroenterologia de MexicoSwallowing and pharyngo-esophageal manometry in obstructive sleep apnea
2015, Brazilian Journal of OtorhinolaryngologyCitation Excerpt :Esophageal pressure measures did not differ between the groups with and without dysphagia. The finding of LES hypotonia, which can be associated with gastroesophageal reflux disease (GERD),37 was present in both groups (p = 0.32), but since it was an exclusion criteria, our patients had no symptoms suggestive of the disease. The association between GERD and OSA has been described in the literature,38,39 but was not evaluated in this study.
High prevalence of esophagitis in patients with severe ineffective esophageal motility: need for a new diagnostic cutoff
2022, Annals of GastroenterologyChicago classification version 4.0 and its impact on current clinical practice
2021, Gastroenterology and HepatologyCharacterization of esophageal motility disorders in refractory gastroesophageal reflux disease patients with esophageal symptoms
2021, Revista Colombiana de Gastroenterologia