Esophageal Manometry
Chhaya Hasyagar, MD
Gastroenterology
Kaiser, Sacramento
Objectives
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Review esophageal anatomy
Role of esophageal manometry testing
Review manometry tracings
Anatomy
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18- to 25-cm long
muscular tube
cervical and thoracic
parts.
wall is composed of
striated muscle in the
upper part, smooth
muscle in the lower
part, and a mixture of
the two in the middle.
Esophageal Motility
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Three separate stages:
– Voluntary or oral stage.
– Pharyngeal stage.
– Esophageal stage.
Esophageal Motility
Esophagus Diagnostic
procedures
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Morphologic diagnostics
– Esophageal radiography
– Endoscopy
– Pill cam ESO
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Functional diagnostics
–
–
–
–
Esophageal manometry
Esophageal pH monitoring
Esophageal impedance
Radionuclide 99 mTC scintiscanning
Esophageal Manometry
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When does it help?
– Functional disorder is suspected
– Unrevealing morphological studies
– Part of pre-operative evaluation
Water Perfused System
Water Perfused System
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Advantages
– Cost effective
– Flexibility in configuration
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Disadvantages
– Slow response rate
– Less suitable for UES and pharynx
– Need for skilled personnel for use and
maintenance
Solid state Catheters
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Catheters have miniature
strain gauge transducers
built into the catheter to
generate electrical output
signals
Solid State Catheters
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Advantages
– Fast response
– No water perfusion
– Easy to use and calibrate
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Disadvantages
–
–
–
–
Expensive
Limited number sensors
Fragile
Functional lifespan
Esophageal Manometry
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Three steps:
– LES
– Body
– UES
Esophageal Manometry
ManoScan™ / HRM
Overview
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Automatically captures all
motor function from
pharynx to stomach
Reduces data acquisition
times by more than 60%
Simplifies procedures and
technician training
Yields portable &
reproducible data sets
Normal Study Using
™
ManoScan Line Trace
Mode
UES
LES
Normal study
Case 1
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48 year old female with long standing
heartburn
Symptoms well controlled on PPIs for
5 years
Now with recurrence of symptoms
despite high dose PPI
EGD: hiatal hernia otherwise normal
Esophageal manometry
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24 hour pH confirmed acid reflux
Proceeded with surgery for management of
GERD
Case 2
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36 year old archeologist with gradual onset
of fatigue and dysphagia.
Difficulty with drinking water
Returned from a trip to the Amazon basin 6
months ago
EGD: Normal except for a “pop” felt while
advancing scope into the stomach
Next step?
HREM
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Aperistalsis in the
smooth muscle portion
of the body of the
esophagus.
elevated resting LES
pressure: >45 mmHg
incomplete LES
relaxation after a
swallow
“common channel effect”
Achalasia
Dilated esophagus
Bird beak
appearance
Achalasia
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Idiopathic or acquired – Chagas
disease
Increases risk of squamous cell CA
Chagas disease – parasite
Trypanosoma cruzi, transmitted by
“kissing bug”
Achalasia - Management
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Endoscopic:
– botulinum toxin
injection of LES,
pneumatic dilation
of LES
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Surgical:
– Hellers myotomy
(usually with antireflux
fundoplication)
Case 3
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50 year old female seen in the ER 4
times with sudden onset of chest
pressure.
Cardiac workup including stress test
was negative
EGD: normal
Next step?
Diffuse esophageal Spasm
(DES)
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Frequent simultaneous contractions (>20-30%) with interval normal
contractions.
Confined distal 2/3.
Multiphasic waves.
Prolonged duration.
Spontaneous contractions
High amplitude of the contractions
DES
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Rosary Bead or
corkscrew
esophagus
Treatment:
–
–
–
–
CCB (diltiazem)
nitrates (isosorbide)
Sildenafil
TCA (imipramine)
Nutcracker Esophagus
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high amplitude
peristaltic contractions
in the distal 10 cm of
the esophagus
average distal
esophageal peristaltic
pressures >220 mmHg
Increased distal
peristaltic duration
(mean value >6 sec)
Case 4
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55 year old female with intolerance to cold, heartburn not
responding to medications, with c/o dysphagia to solids for 8 months
Wears gloves in summer as her fingers turn blue to purple in AC
rooms
Upper endoscopy: normal, no webs or rings
Next step?
Scleroderma
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Pathophysiology:
– alterations of the
microvasculature,
the autonomic
nervous system,
and the immune
system, leading to
fibrosis
– Affects lower 2/3 of
esophagus
Esophageal impedance
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Measures changes in resistance to
alternating electrical current when a
bolus passes through a ring
Liquid containing boluses will lower
the impedance to a nadir value
Gas will produce a rapid rise in
impedance
Esophageal Impedance
Esophageal motility disorders
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Primary disorders
– Achalasia
– Diffuse esophageal spasm
– Nutcracker esophagus
– Ineffective motility disorder
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Secondary disorders
– Scleroderma
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Disclosure: none
Questions