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British Society of Gastroenterology Guidelines for Oesophageal Manometry and Oesophageal Gut: First Published As 10.1136/Gutjnl-2018-318115 on 31 July 2019

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British Society of Gastroenterology Guidelines for Oesophageal Manometry and Oesophageal Gut: First Published As 10.1136/Gutjnl-2018-318115 on 31 July 2019 Guidelines British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal Gut: first published as 10.1136/gutjnl-2018-318115 on 31 July 2019. Downloaded from reflux monitoring Nigel J Trudgill, 1 Daniel Sifrim,2 Rami Sweis,3 Mark Fullard,4 Kumar Basu,5 Mimi McCord,6 Michael Booth,7 John Hayman,8 Guy Boeckxstaens,9 Brian T Johnston,10 Nicola Ager,8 John De Caestecker11 1Sandwell and West Birmingham ABSTRact GRADE evidence: Moderate Hospitals NHS Trust, West These guidelines on oesophageal manometry and Strength recommendation: Conditional/weak Bomwich, UK 2Centre of Gastroenterology gastro-oesophageal reflux monitoring supersede 1.3 Normal values for HRM are manufacturer and Research, Queen Mary those produced in 2006. Since 2006 there have been catheter specific. University London, London, UK significant technological advances, in particular, the GRADE evidence: High 3 University College London development of high resolution manometry (HRM) and Strength recommendation: Strong Hospitals NHS Foundation Trust, oesophageal impedance monitoring. The guidelines London, UK 1.4 Adjunctive testing (eg, larger volumes of water, 4West Hertfordshire were developed by a guideline development group solid/viscous swallows or a test meal) can provide Hospitals NHS Trust, Watford, of patients and representatives of all the relevant additional information and unmask pathology not Hertfordshire, UK professional groups using the Appraisal of Guidelines 5 seen with standard water swallows, as they are more Sheffield Teaching Hospitals for Research and Evaluation (AGREE II) tool. A NHS Foundation Trust, Sheffield, representative of normal swallowing behaviour UK systematic literature search was performed and the and more likely to induce symptoms and, in turn, 6Heartburn Cancer UK, GRADE (Grading of Recommendations Assessment, improve diagnostic yield. Baingstoke, UK Development and Evaluation) tool was used to evaluate GRADE evidence: High 7Royal Berkshire NHS the quality of evidence and decide on the strength of the Strength recommendation: Strong Foundation Trust, Reading, UK recommendations made. Key strong recommendations 8Sandwell and West Birmingham Hospitals NHS Trust, West are made regarding the benefit of: (i) HRM over standard Bromwich, UK manometry in the investigation of dysphagia and, in Patients with dysphagia 9Gastroenterology, University particular, in characterising achalasia, (ii) adjunctive 1.5 Patients with dysphagia should preferably Hospital, KU Leuven, Leuven, testing with larger volumes of water or solids during have an endoscopy with oesophageal biopsies to http://gut.bmj.com/ Belgium 10Department of HRM, (iii) oesophageal manometry prior to antireflux rule out and treat mucosal and structural disor- Gastroenterology, Belfast Health surgery, (iv) pH/impedance monitoring in patients with ders prior to manometry. Barium swallow should and Social Care Trust, Belfast, reflux symptoms not responding to high dose proton be considered where endoscopy is not possible UK 11 pump inhibitors and (v) pH monitoring in all patients and/or where structural disorders require further University Hospitals of with reflux symptoms responsive to proton pump Leicester NHS Trust, Leicester, scrutiny. UK inhibitors in whom surgery is planned, but combined pH/ GRADE evidence: Moderate impedance monitoring in those not responsive to proton Strength recommendation: Strong on September 27, 2021 by guest. Protected copyright. Correspondence to pump inhibitors in whom surgery is planned. This work Dr Nigel J Trudgill; has been endorsed by the Clinical Services and Standards nigel. trudgill@ nhs. net Committee of the British Society of Gastroenterology Patients with achalasia (BSG) under the auspices of the oesophageal section of 1.6 In patients with achalasia, HRM provides infor- Received 14 December 2018 Revised 13 June 2019 the BSG. mation on achalasia subtype which is predictive of Accepted 16 June 2019 clinical outcome. Although also possible, subtyping Published Online First achalasia with standard manometry requires 31 July 2019 expertise. SUMMARY OF ALL RECOMMENDATIONS GRADE evidence: Moderate 1. Oesophageal manometry, including high Strength recommendation: Strong resolution manometry Technical aspects of oesophageal manometry 1.1 In patients undergoing evaluation for dysphagia, Patients with major motility disorders other than high resolution manometry (HRM) is superior to achalasia (diffuse oesophageal spasm, hypercontractile standard manometry in terms of reproducibility, oesophagus, absent peristalsis) © Author(s) (or their 1.7 Among patients with major motility disorders employer(s)) 2019. Re-use speed of performance and ease of interpretation permitted under CC BY-NC. No GRADE evidence: High other than achalasia (diffuse oesophageal spasm, commercial re-use. See rights Strength recommendation: Strong hypercontractile oesophagus, absent peristalsis), and permissions. Published 1.2 The addition of impedance to HRM can be HRM, compared with standard manometry, may by BMJ. a helpful adjunct to ‘visualise’ bolus movement provide increased diagnostic and functional infor- To cite: Trudgill NJ, Sifrim D, and peristalsis effectiveness; however, its utility in mation changing intervention. Sweis R, et al. Gut clinical practice and impact on therapeutic deci- GRADE evidence: Moderate 2019;68:1731–1750. sion making is not yet clear. Strength recommendation: Conditional/weak Trudgill NJ, et al. Gut 2019;68:1731–1750. doi:10.1136/gutjnl-2018-318115 1731 Guidelines Patients undergoing catheter based reflux monitoring such demonstration of pathological gastro-oesophageal reflux 1.8 Oesophageal manometry is the preferred method by which disease. to localise the lower oesophageal sphincter (LOS) prior to cath- GRADE evidence: Low Gut: first published as 10.1136/gutjnl-2018-318115 on 31 July 2019. Downloaded from eter based pH sensor placement. Strength recommendation: Conditional/weak GRADE evidence: Moderate 2.5 In patients with heartburn, acid regurgitation or chest pain, Strength recommendation: Strong symptom association with reflux episodes is best assessed with both the symptom association probability and symptom index. Patients prior to antireflux surgery GRADE evidence: Low 1.9 Although there is currently no evidence to rule out or tailor Strength recommendation: Conditional/weak antireflux surgery in patients with minor motor disorders, 2.6 In patients with throat or respiratory symptoms, dual probe oesophageal manometry should be performed in advance of all distal oesophageal and proximal oesophageal or pharyngeal pH patients being considered for surgery to rule out LOS dysfunc- monitoring has no advantage over single probe distal oesopha- tion (ie, achalasia), as well as major motor disorders of the geal pH monitoring. oesophageal body (eg, diffuse oesophageal spasm). GRADE evidence: Low GRADE evidence: High Strength recommendation: Conditional/weak Strength recommendation: Strong Patients with symptoms suspected to be due to gastro-oesophageal Symptomatic patients after antireflux surgery reflux disease 1.10 HRM can provide useful diagnostic information not obtain- 2.7 Patients with symptoms suspected to be due to gastro-oe- able by standard manometry, among patients with dysphagia sophageal reflux disease should undergo a therapeutic trial of a after antireflux surgery. proton pump inhibitor as the initial diagnostic approach. GRADE evidence: Low GRADE evidence: Moderate Strength recommendation: Conditional/weak Strength recommendation: Strong 2.8 Reflux monitoring with pH or pH/impedance is not recom- Patients with suspected rumination mended in patients with gastro-oesophageal reflux disease symp- 1.11 Rumination syndrome can be confidently diagnosed clin- toms responsive to proton pump inhibitor therapy in whom ically on the basis of a typical history, but if the diagnosis is antireflux surgery is not planned. unclear, the patient needs convincing of the diagnosis or objec- GRADE evidence: Moderate tive evidence is required prior to therapy, HRM with impedance Strength recommendation: Strong after a test meal can be utilised to identify diagnostic features. 2.9 In patients with heartburn or regurgitation not responding Simultaneous impedance provides additional confirmatory and to twice daily proton pump inhibitors, reflux monitoring should diagnostic information. be performed with pH/impedance monitoring. This technique GRADE evidence: Moderate allows diagnosis of increased acid exposure, association between http://gut.bmj.com/ Strength recommendation: Strong symptoms and acid or non-acid reflux, and identification of phenotypes—ie, non-erosive reflux disease, hypersensitive oesophagus and functional heartburn. 2. Catheter based oesophageal reflux monitoring, including GRADE evidence: Moderate pH and impedance monitoring Strength recommendation: Strong Technical aspects of reflux monitoring 2.10 In patients with chest pain, throat or respiratory symptoms 2.1 Automatic analysis of oesophageal pH recordings and suspected to be due to gastro-oesophageal reflux disease but not symptom association with acid reflux episodes is adequate for responding to twice daily proton pump inhibitors, we recommend on September 27, 2021 by guest. Protected copyright. pH monitoring in patients, provided the recording is checked for performing reflux monitoring with pH/impedance, as this enables artefacts and major technical issues and that times of meals and the diagnosis of pathological gastro-oesophageal reflux and/or an
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