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OBJECTIVE: Accurate placement of a pH electrode requires manometric localization of the lower esophageal sphincter (LES). Combined manometry/pH devices using water-perfused tubes attached to pH catheters and the use of an electronic "LES locator" have been reported. We investigated whether accurate placement of pH probes can be achieved using such a probe, and whether this may reduce the need for the performance of the usual stepwise pull-back manometry. METHODS: Thirty consecutive patients (15 men, 15 women; median age, 56 yr; interquartile range, 42-68 yr) referred for manometry and pH testing were included in the study. The localization of the LES was determined with standard esophageal manometry. After that, a second 3-mm pH electrode with an internal perfusion port was passed into the stomach. Using this catheter, a single stepwise pull-through manometry was performed and the LES position was noted. LES location, mean pressure, and length obtained with standard manometry were compared to data from the combined pH/manometry catheter. Additionally the time necessary to perform each of the procedures was noted and the patient's discomfort caused by the catheter was evaluated using a standardized questionnaire. RESULTS: The LES location with the pH/manometry probe was proximal to that with standard manometry in 19 patients (63%), the same in nine patients (30%), and distal in two patients (7%). The differences were <2 cm in 29 of 30 (97%) patients. The LES location with the pH/manometry probe required a median of 6.5 min (interquartile range: 3.5-8.5 min) versus a median of 21.5 min (interquartile range: 14.5-26.5 min) for standard manometry (p < 0.0001). In addition, LES evaluation using the combined pH/manometry probe provided accurate data on the resting pressure, as well as overall and intraabdominal length of the LES. All patients tolerated the combination probe better than the standard manometry probe (p < 0.001). CONCLUSIONS: Placement of the esophageal electrode for 24-h esophageal pH monitoring using a combined pH/manometry probe is accurate. The technique is simple, time-saving, and convenient for the patients. Because it is possible to accurately evaluate the LES using this technique, it may even replace conventional manometry before pH probe placement.
PURPOSE: To evaluate retrospectively the presence of complete relaxation of the lower esophageal sphincter (LES) at manometry in patients with achalasia depicted on barium esophagograms. MATERIALS AND METHODS: The institutional review board approved this retrospective study and did not require informed consent. A search of radiology and manometry records identified 21 patients (12 men, nine women; mean age, 52.4 years) with achalasia depicted on barium esophagograms who had undergone manometric examinations and met the inclusion criteria. Radiologic reports and images were reviewed for presence or absence of primary peristalsis, impaired LES opening, esophageal dilatation, delayed emptying of barium, and nonperistaltic contractions. Manometry reports were reviewed for presence or absence of peristalsis or simultaneous esophageal contractions. Resting and residual LES pressures were recorded to determine whether LES relaxation was complete or incomplete. Medical records were reviewed to determine clinical presentation and follow-up (treatment and patient course), and radiographic files were reviewed to determine radiographic findings at follow-up examinations. Clinical characteristics (eg, age, dysphagia, and weight loss) were correlated with LES relaxation at manometry. Data were analyzed statistically with Fisher exact and Wilcoxon rank sum testing. RESULTS: All 21 patients with radiographic findings of achalasia had aperistalsis at manometry. Fourteen patients (67%) had incomplete LES relaxation at manometry during swallowing, and seven (33%) had complete LES relaxation. There were no significant differences between patients with complete LES relaxation and those with incomplete LES relaxation in mean age (P = .59), duration of dysphagia (P = .18), or weight loss (P > .99). Clinical follow-up findings were available for six patients with complete LES relaxation at manometry and 10 with incomplete relaxation. Symptoms resolved after treatment in all six patients with complete LES relaxation. Six (60%) of 10 patients with incomplete LES relaxation had resolution of symptoms after treatment, and four (40%) had substantial improvement. CONCLUSION: These data suggest that in patients with typical radiographic findings of achalasia, the barium study can be used to guide treatment without a need for manometry. If radiographic findings are equivocal, however, manometry may be required for a more certain diagnosis.
Our aim was to review the use of esophageal investigations in patients with suspected connective tissue disease (CTD). Forty-seven patients (39 women and 8 men) with suspected CTD were referred for esophageal manometry at the gastrointestinal physiology unit in the Royal Victoria Hospital, Belfast, U.K., over a 10-year period (1987-1997). The mean age was 51.7 years (range = 21-79 years). Chart review was conducted 1 to 10 years after manometry to confirm the final diagnoses: scleroderma was found in 11; CREST (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia), 8; mixed connective tissue disease, 14; Raynaud's alone, 5; and other CTDs, 9. All 47 successfully underwent esophageal manometry. In addition to manometry, 24 underwent gastroscopy; 27, barium meal; and 3, esophageal pH studies. Clinically significant esophageal abnormalities were noted in 8 (33%) on gastroscopy, in 15 (56%) on barium meal, and in 31 (66%) on manometry. Gastroscopy had a significantly lower positivity rate than the others (p < 0.05). Only three patients had pH testing, yet all three pH tests were abnormal. During manometry, abnormal findings were significantly more common in scleroderma-CREST when compared with other diagnoses (89% vs. 50%; p < 0.02). Thirty-three patients reported dysphagia. Abnormal manometry was more likely in these cases (82% vs. 33%; p < 0.02). A high percentage of patients with CTD have significant esophageal motility disorders. Investigations were more likely to be positive with scleroderma-CREST than other CTDs, even if dysphagia was present. Barium meal and manometry are more useful than OGD. pH studies were under-used. There is need for a standardized approach to esophageal investigations in patients with CTDs.
The results of a cardiologic work-up in patients with retrosternal pain are negative in about 20-30% of cases. Overall one half of these patients exhibit an esophageal dysfunction. In order to diagnose esophageal dysfunction long-term pH-metry, transit scintigraphy and standard manometry are used as well as provocation tests. New diagnostic procedures such as long-term manometry and combined long-term pH-metry and manometry have recently been developed and are increasingly used. Long-term pH-metry is a valid, uncomplicated and sensitive procedure used to diagnose acid gastroesophageal reflux. The differential diagnosis of hypermotility esophageal dysfunction is, however, considerably more difficult. Scintigraphy appears unsuitable. The value of standard manometry is hindered by the short examination time and the rare possibility to correlate pain episodes and motility disorders. It is therefore recommended that a provocation test should be carried out after standard manometry. Preliminary results for long-term manometry are now available. These show that it is not only possible to correlate pain episodes and motility disorders but also to differentiate pathological manometry profile. This applies also to combined pH-metry and manometry reducing patients discomfort to one examination.
BACKGROUND: Endoscopic biliary manometry is useful in the assessment of patients with types II and III sphincter of Oddi dysfunction, but it is time consuming and invasive. AIM: To investigate the role of (99m)Tc-DISIDA scanning, with and without morphine provocation, as a non-invasive investigation in these patients compared with endoscopic biliary manometry. SUBJECTS AND METHODS: A total of 34 patients with a clinical diagnosis of type II (n = 21) or III (n = 13) sphincter of Oddi dysfunction were studied. Biliary scintigraphy with 100 MBq of (99m)Tc-DISIDA was carried out with and without morphine provocation (0.04 mg/kg intravenously) and time/activity curves were compared with the results of subsequent endoscopic biliary manometry. RESULTS: Eighteen (nine type II, nine type III) of the 34 (53%) patients had sphincter of Oddi basal pressures above the upper limit of normal (40 mm Hg). In the standard DISIDA scan without morphine, no significant differences were observed in time to maximal activity (Tmax) or percentage excretion at 45 or 60 minutes between those with normal and those with abnormal biliary manometry. However, following morphine provocation, median percentage excretion at 60 minutes was 4.9% in those with abnormal manometry and 28.2% in the normal manometry group (p = 0.002). Using a cut off value of 15% excretion at 60 minutes, the sensitivity for detecting elevated sphincter of Oddi basal pressure by the morphine augmented DISIDA scan was 83% and specificity was 81%. Also, 14 of the 18 patients with abnormal manometry complained of biliary-type pain after morphine infusion compared with only two of 16 patients in the normal manometry group (p = 0.001). CONCLUSIONS: (99m)Tc-DISIDA with morphine provocation is a useful non-invasive investigation for types II and III sphincter of Oddi dysfunction to detect those with elevated sphincter basal pressures who may respond to endoscopic sphincterotomy.
Patients with spinal cord lesion suffer from complex disorders of bladder and anorectal function. We assessed the value of urodynamics and anorectal manometry as prognostic and diagnostic tools in these patients and evaluated the usefulness of these techniques for the differentiation between complete and incomplete spinal cord lesions. Thirty patients with suprasacral spinal cord injury (six women, 24 men; mean age, 31 years) underwent anorectal manometry and urodynamics within the first 40 days after injury. The findings were compared to the results of a clinical neurologic evaluation. Fifteen patients were classified as complete lesions on their clinical signs, three of these lesions were incomplete according to urodynamic testing and five were incomplete according to visceral sensory testing by anorectal manometry. Despite significant differences in maximum bladder capacity (589 versus 465 mL), maximum detrusor pressure (18 versus 31 cm H2O) was not significantly different between patients with complete and patients with incomplete spinal cord injury. Anorectal manometry did not reveal any significant differences in resting pressure, abdominal pressure, and maximal rectum volume between these groups. Urodynamics and anorectal manometry may be superior to neurologic assessment of completeness of spinal cord lesions. Urodynamics and anorectal manometry were not helpful in the prediction of onset or severity of detrusor hyperreflexia. Thus, we do not regard anorectal manometry as a standard diagnostic tool in spinal cord injury patients.
PURPOSE: The purpose of this study was to investigate the relationships between the grade of anal sphincter rupture, anal sphincter defect, manometry variables, and anal incontinence. METHODS: A total of 132 females with first-time obstetric sphincter rupture were evaluated by transanal ultrasound, manometry, and scoring of bowel symptoms five months after delivery. RESULTS: Anal sphincter rupture and transanal ultrasound grade correlated with each other ( rs= 0.427, P= 0.001). Both rupture and transanal ultrasound grade correlated with soiling grade ( rs= 0.2, P= 0.03 for both), but in a multiple regression analysis, only transanal ultrasound grade was significant ( P= 0.001) as an independent variable. Anal incontinence score correlated with all the manometry variables, but in a multiple regression analysis, only squeeze pressure was significant ( P= 0.001, beta = -0.4) as an independent variable. Both anal sphincter rupture and transanal ultrasound grade were correlated with manometry variables, but only transanal ultrasound grade was significant as an independent variable after multiple regression analysis. The frequency of transanal ultrasound-verified extensive defect of anal sphincter was higher in rupture Grade 3B (25; 95 percent confidence interval, 12-38 percent) and Grade 4 (45; 95 percent confidence interval, 24-66 percent) than in Grade 3A (2.8; 95 percent confidence interval, -1 to -6.6 percent).(s) (s)CONCLUSION Manometry variables are significantly lower in incontinent females than in continent females, and the Wexner incontinence score was correlated with manometry variables. Both anal sphincter rupture and transanal ultrasound grade correlated with soiling grade and with manometry variables, but in both cases only the transanal ultrasound grade was a significant independent variable.
PURPOSE: Traditional methods of identifying patients with persistent dilation of the rectum, or megarectum, are associated with inherent methodologic limitations. The purpose of this study was to use a barostat to establish criteria for the diagnosis of megarectum and to assess rectal diameter during isobaric (barostat) and volumetric (barium contrast) distention protocols in constipated patients with megarectum on anorectal manometry. METHODS: During fluoroscopic screening, rectal diameter was measured at minimum distending pressure of the rectum, achieved using a barostat. It was also measured during evacuation proctography (volumetric distention). Having established a normal range in 25 healthy volunteers, 30 constipated patients with evidence of megarectum on anorectal manometry (elevated maximum tolerable volume on latex balloon distention) were studied. A further 10 constipated patients without evidence of megarectum were studied (normal rectum). RESULTS: Megarectum was diagnosed when the rectal diameter was greater than 6.3 cm at minimum distending pressure. Rectal diameter at minimum distending pressure was increased in 20 patients (67 percent) with megarectum on anorectal manometry, but was normal in the remaining 10 patients (33 percent) and all patients with a normal rectum on anorectal manometry. Rectal diameter was increased at evacuation proctography in only 15 patients (50 percent) with evidence of megarectum on anorectal manometry. CONCLUSIONS: The prevalence of megarectum is overestimated and underestimated when rectal diameter is assessed using anorectal manometry and contrast studies, respectively. Controlled (pressure-based) distention combined with fluoroscopic imaging allowed accurate identification of patients with megarectum on the basis of a rectal diameter greater than 6.3 cm at the minimum distention pressure. Measurement of rectal diameter at minimum distention pressure may be useful in those patients with an elevated maximum tolerable volume on anorectal manometry when surgery is being contemplated.
With the introduction of endoscopic retrograde cholangiopancreatography (ERCP) manometry, the characteristics of sphincter of Oddi (SO) motor activity have been described. SO manometry is the only available method to measure SO motor activity directly and is usually performed at the time of ERCP. SO manometry is considered to be the gold standard for evaluating patients for sphincter dysfunction. This review reports the technique of SO manometry and normal values for SO manometry. SO motility is characterized by prominent phasic contractions superimposed on a tonic pressure. Elevated basal SO pressure is the most consistent and reliable criteria to diagnose SO dysfunction. Basal pressures obtained from the biliary sphincter are similar to the basal pressure obtained from the pancreatic sphincter. Abnormal SO manometric values are shown. Factors that influence SO pressures, and interpretation of SO manometric tracing are discussed. The most common and serious complication of SO manometry is post-manometry pancreatitis. In healthy volunteers with normal sphincter function, pancreatitis is almost never seen. However, in patients with SO dysfunction, the incidence of pancreatitis is high. The use of new nonperfused microtransducers may reduce this complication.
The development of miniaturized electronic pressure transducers and portable digital data recorders with large storage capacity has made ambulatory monitoring of esophageal motor function over an entire circadian cycle possible. The broad clinical application of this new technology in a large number of asymptomatic normal volunteers and patients with primary esophageal motor disorders or gastroesophageal reflux disease provides new insights into esophageal motor function in health and disease under a variety of physiologic conditions. In normal volunteers and symptomatic patients, esophageal motor activity increases with both the state of consciousness and eating activity, i.e., from sleep to awake to meal periods. In the normal situation there is a higher prevalence of nonperistaltic esophageal contractions than appreciated on stationary manometry. Compared with standard manometry, ambulatory esophageal manometry provides a more than 100-fold larger database for the classification and quantitation of abnormal esophageal motor function and leads to a change in the diagnosis in a substantial portion of patients with symptoms suggestive of a primary esophageal motor disorder. In patients with nonobstructive dysphagia, the circadian esophageal motility pattern is characterized by an inability to organize the motor activity into peristaltic contractions during meal periods. In patients with noncardiac chest pain, ambulatory motility monitoring can document a direct correlation of abnormal esophageal motor activity with the symptom and shows that the abnormal motor activity immediately preceding the pain episodes is characterized by an increased frequency of simultaneous, double- and triple-peaked, high-amplitude, and long-duration contractions. A long esophageal myotomy can abolish the ability of the esophagus to produce this abnormal motor pattern. In patients with gastroesophageal reflux disease, ambulatory motility monitoring shows that the contractility of the esophageal body deteriorates with increasing severity of esophageal mucosal injury, compromising the clearance function of the esophageal body. These data suggest that ambulatory esophageal motility monitoring allows for a more precise classification of esophageal motor disorders than standard manometry and can identify abnormal esophageal motor pattern associated with nonobstructive dysphagia, noncardiac chest pain, or gastroesophageal reflux. Ambulatory esophageal manometry therefore should replace standard manometry in the assessment of esophageal body function and has potential to improve the diagnosis and management of patients with esophageal motor abnormalities. The combination of ambulatory 24-hour esophageal manometry with esophageal and gastric pH monitoring is currently the most physiologic way to assess patients with functional foregut disorders.
Criteria for diffuse oesophageal spasm(DOS) are dysphagia and chest pain with oesophageal manometry showing retention of peristalsis with the presence of synchronous contractions in response to wet swallows. Because of the intermittent nature of the symptoms, edrophonium was used as a provocative agent to increase diagnostic yield. Three hundred and ninety-six patients underwent transnasal manometry using a Gaeltec system of six internal transducers arranged at 5 cm intervals from the catheter tip; the majority of these patients received 10 mg edrophonium as an intravenous bolus. Reproduction of symptoms with typical manometry of DOS indicated a positive provocation test. There were no significant side effects. DOS was diagnosed in 34 patients who had either the typical manometry or a positive provocation test. Thirty of these patients received edrophonium. Twenty patients had baseline manometry which was diagnostic and ten of this group had a positive provocation test. The remaining 10 patients, who had normal baseline manometry, had positive provocation tests following the injection of edrophonium. Without edrophonium provocation testing, about a third of patients would not have been diagnosed as having DOS.
PURPOSE: A significant proportion of patients with slow-transit constipation have abnormal small-bowel motility. It is unclear whether abnormal small-bowel motility indicates worse results after surgery for slow-transit constipation. We studied the results of colectomy with ileorectal anastomosis in patients with normal and abnormal antroduodenal manometry findings. METHODS: Seventeen, consecutive patients who had been referred for intractable constipation and who were found to suffer from slow-transit constipation underwent subtotal colectomy. All patients underwent a set of diagnostic investigations, including whole gut transit time, anorectal manometry, antroduodenal manometry, electromyography of the anal sphincter, balloon expulsion test, and defecography. Patients were followed up after five years. RESULTS: Patients' median age at the time of the operation was 46 (range, 23-70) years, and the median duration of constipation was 31 (range, 11-65) years. One patient died 21 days after the operation. Three patients developed intestinal pseudo-obstruction after the operation, and two of these died during the follow-up period. Fourteen patients were available for follow-up after a median of five (range, 4-7) years. Bowel frequency was significantly increased from a median of 0 (range, 0-2) times per week to a median of 30 (range, 10-102) times per week after surgery (P<0.001). The incidence of abdominal pain decreased from 94 to 43 percent. Seven of 13 patients (54 percent) continued to have bloating. At long-term follow-up, 12 of 14 patients (86 percent) reported that they had an overall improvement after surgery, despite continuing pain and bloating in a significant proportion of them. The outcome of surgery was good or excellent in seven of seven patients with normal findings on antroduodenal manometry, but only five of nine patients with abnormal manometry findings attained a good result after surgery. We found a trend (P=0.09) toward better long-term results after surgery for slow-transit constipation in patients with a normal antroduodenal manometry before the operation.
Diffuse esophageal spasm (DES) and achalasia share both clinical and manometric characteristics. Some reports support the notion of progression of DES to achalasia. However, there are currently no prospective data in support of this theory. To assess prospectively the rate of manometric progression of DES to achalasia. Manometry tracings of DES patients diagnosed between 1992 and 2003 were independently reviewed blindly and agreed on by two esophageal experts. Patients with DES who agreed to undergo repeat esophageal manometry constituted the study cohort. Follow-up manometry tracings were evaluated blindly and independently by the same two interpreters to determine the rate of manometric progression to achalasia. Predictors of manometric progression were assessed. A total of 32 patients were diagnosed with DES between 1992-2003. Twelve patients (9M/3F; median age 62 years) agreed to participate and underwent second manometry (mean +/- SD follow-up of 4.8 +/- 3.4 years). Achalasia was diagnosed on follow-up manometry in one patient (8%), seven (58%) patients continued to have DES, three (25%) had normal motility, and one (8%) had nutcracker esophagus. There were no predictors of progression to achalasia based on the initial manometry parameters. A subgroup of DES patients with initial low esophageal body amplitude developed increase in esophageal simultaneous contractions on follow-up similar to the patient who evolved to achalasia. Following were the results. 1) Progression from DES to achalasia is uncommon. 2) DES patients with low esophageal body amplitude may develop increased simultaneous contractions over time. 3) DES remains an elusive diagnosis clinically and manometrically.