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AGA Technical Review on the Clinical Use of Esophageal Manometry

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AGA Technical Review on the Clinical Use of Esophageal Manometry GASTROENTEROLOGY 2005;128:209–224 AGA Technical Review on the Clinical Use of Esophageal Manometry This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice Committee. The paper was approved by the Committee on October 2, 2004, and by the AGA Governing Board on November 7, 2004. he utility of esophageal manometry in clinical prac- function. In general, manometric data are only as valid as Ttice resides in 3 domains: (1) to accurately define the methodology used to acquire them. esophageal motor function, (2) to define abnormal motor The frequency content of esophageal contractile waves function, and (3) to delineate a treatment plan based on defines the required characteristics of a manometric re- motor abnormalities. Since the first American Gastroen- cording device. The frequency response required to re- terological Association technical review on esophageal produce esophageal pressure waves with 98% accuracy is manometry published 10 years ago,1,2 advances have 0–4 Hz, while that required for reproducing pharyngeal been made within each of these domains. By and large, pressure waves is 0–56 Hz.3 Expressed in terms of max- these advances have not been the result of major techno- imal recordable ⌬P/⌬t, 300 mm Hg/s will suffice for the logical changes but rather a reflection of improved man- mid or distal esophagus versus 4000 mm Hg/s for the ometric technique and research. With this in mind, the pharynx. Because the overall characteristics of the man- goal of this second technical review on the clinical use of ometric system are only as good as those of the weakest esophageal manometry is to summarize what has been element within that system, high-fidelity recordings re- learned during the past 10 years and discuss how this has quire that each element (pressure sensor, transducer, modified the clinical management of esophageal disor- recorder) meet or exceed these response characteristics. ders. Thus, we performed a literature search for all Modern computer polygraphs and pressure transducers, English-language articles dealing with manometric eval- essentially unchanged in the past 10 years, have response characteristics greatly exceeding those required for uation of the esophagus from 1994 to 2003. The data- esophageal manometry. Thus, most of the methodolog- bases searched included MEDLINE, PreMEDLINE, and ical evolution that has occurred during the past 10 years PubMed using general terms related to manometric tech- has been in the domains of manometric assembly design nique (sleeve, topography) and equipment (water per- and data analysis; each of these will be reviewed. fused, solid state), esophageal symptoms (dysphagia, chest pain, heartburn), esophageal disorders and proce- Manometric Assemblies dures (gastroesophageal reflux disease, achalasia, diffuse The pressure sensor/transducer components of a esophageal spasm, nutcracker esophagus, hypertensive manometric assembly function as a matched pair and are LES, nonspecific motor disorders, ineffective esophageal available in 2 general designs: water-perfused catheters motility, fundoplication, myotomy, dilation), and terms with volume displacement transducers or strain gauge focused on esophageal motor function (upper esophageal transducers with solid-state circuitry. Major advantages sphincter, lower esophageal sphincter, esophageal body, of water-perfused systems are cost and versatility. A peristalsis). Additional references were identified from major disadvantage is that the equipment is fickle and references of reviewed manuscripts. proper maintenance requires skilled personnel. Illustra- tive of the versatility possible with perfused manometric 1994–2003: How Has Esophageal assemblies, the past 10 years have witnessed the intro- Manometry Changed? duction of multilumen, autoclavable, miniature silicone Manometry is by nature a highly technical eval- Abbreviations used in this paper: DES, diffuse esophageal spasm; uation, more akin to physiologic studies than to endo- EGJ, esophagogastric junction; GERD, gastroesophageal reflux dis- scopic or radiographic ones. When optimally utilized ease; IEM, ineffective esophageal motility; tLESR, transient lower and providing that physical principles and equipment esophageal sphincter relaxation; UES, upper esophageal sphincter. © 2005 by the American Gastroenterological Association characteristics are respected, a manometric examination 0016-5085/05/$30.00 provides an accurate description of esophageal contractile doi:10.1053/j.gastro.2004.11.008 210 AMERICAN GASTROENTEROLOGICAL ASSOCIATION GASTROENTEROLOGY Vol. 128, No. 1 extrusions that can be configured with nearly infinite ization of what has otherwise been a highly operator- variety. dependent evaluation. However, the pitfalls of interpret- Faithful recording of sphincter pressure for extended ing esophageal manometric tracings are plentiful. For periods of time or during swallow-related esophageal example, pressure thresholds established to distinguish shortening requires that the pressure sensor maintain a contractions from miscellaneous artifacts may ignore hy- constant position within the high-pressure zone. Sleeve potensive peristaltic contractions below that threshold. sensors were devised to meet these requirements. How- Similarly, the ability of automated analysis to accurately ever, sleeve sensors were originally made of molded characterize the adequacy of lower esophageal sphincter silicone and, before 1994, manometric extrusions were (LES) relaxation or to differentiate isobaric common cav- made of polyvinyl chloride. Thus, the sleeve sensor ities from spastic contractions has not been adequately needed to be joined to the end of the polyvinyl extrusion validated. These subtle distinctions can be absolutely with a complex joint involving metal stents and suture. crucial in establishing an accurate diagnosis. Thus, al- Although functional, the resultant assembly probably though currently available programs may be useful ad- would not meet current requirements for reuse mandated juncts in the interpretation of (normal) manometric re- by the need for restoring sterility. On the other hand, the cordings, automated analysis has not yet matured to a multilumen silicone extrusions currently available (Mui degree that it can replace manual inspection by an ex- Scientific, Mississauga, Canada; formerly Dentsleeve) can perienced clinician. Guidelines for performance of esoph- incorporate sleeve sensors directly onto the extrusion, ageal manometry and standardized reporting are crucial making the resultant assembly both more durable and to decrease the degree of subjective interpretation be- autoclavable. These catheters have undergone rigorous tween clinicians. Although not covered in this review, reuse evaluation and have been deemed safe for reuse by detailed methods regarding these issues were recently both the Food and Drug Administration (via the 510k published by members of the American Motility Society mechanism) and EU regulators (CE marked and and the European Society of Neurogastroenterology and monitored). Motility Working Group on Esophageal Manometry.6 An alternative to perfused manometric systems is a An offshoot of the introduction of multilumen min- manometric assembly incorporating miniature strain iature extrusions has been the application of topographic gauge sensors and solid-state electronic components. The data presentation to manometric recordings. Topo- microtransducers directly interface with the recorder, graphic analysis is a method of axial data interpolation and the resultant system has a vastly expanded frequency derived from computerized plotting of data from multi- response suitable for pharyngeal recording. On the neg- ple, closely spaced recording sites.7 The interpolated ative side, solid-state systems are much more expensive, pressure information is plotted as either a 3-dimensional are less modifiable, are more delicate, and do not yet have surface plot or a 2-dimensional contour plot in which the versatility of assembly design permissive of either a pressure amplitude is represented by concentric rings or sleeve sensor or topographic data presentation (see fol- color gradients with an appropriate scale (Figure 1). The lowing text). Improvements in design are currently un- advantage of this presentation is that it provides a com- der way, and it is likely that high-resolution solid-state plete, dynamic representation of peristalsis at every axial systems will be available in the near future. One other position along the esophagus, as opposed to the frag- appeal of solid-state systems is that they are not subject mented data presented in conventional manometric trac- to hydrostatic effects and can be miniaturized, factors ings. However, even though this technique has provided that make them more suitable for extended ambulatory significant insight into the physiology of peristalsis and studies. Having said that, recent research has shown has the potential to redefine the way we evaluate sphinc- successful use of a portable water-perfusion pump with a ter relaxation, it is debatable as to whether or not it has sleeve assembly and the resultant publications have pro- yet demonstrated any clear advantage over conventional vided substantial insight into the pathogenesis of reflux4 manometry in clinical practice.8 and the mechanisms of reflux in patients with and with- Intraluminal Impedance Monitoring out a hiatus hernia.5 Although manometric apparatus has not Manometric Data
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