Esophageal Manometry in Gastroesophageal Reflux Disease

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Key points

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    High-resolution manometry (HRM) is an effective tool to study pathophysiologic motor events in gastroesophageal reflux disease (GERD).

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    HRM has clinical utility in excluding esophageal outflow obstruction mimicking GERD.

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    Preoperative esophageal HRM can alter surgical decisions and is of clinical value before antireflux surgery.

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    Provocative testing during HRM may assess esophageal smooth muscle peristaltic reserve.

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.

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