Is a classification of esophageal manometric abnormalities possible ?

G. Vantrappen (Leuven)

Any classification of esophageal manometric abnormalities should encompass data on the motility of both the esophageal body and the lower esophageal sphincter. Moreover, esophageal manometry should include a quantitative study of the distal 10 cm of the esophageal body and of the lower esophageal sphincter, and (at least) a qualitative study of the upper part of the esophagus, composed of striated muscle.

Evaluation of the distal esophageal body should include quantitative measurements of the peristaltic performance of the gullet i.e. the percentage of the deglutitive responses that have a sequential or a simultaneous onset; it should also include quantitative measurements of contraction parameters i.e. amplitude, duration and shape (e.g. double-peaked, multi-peaked, repetitive) of the pressure waves.

Evaluation of the lower esophageal sphincter should include assessment of the basal LES pressure, recorded as the mean of peak values obtained during a pull-through maneuver and assessment of the degree of relaxation, reported as residual pressure above fundic pressure.

The following example may illustrate the ideas behind this classification.

If in a given patient all deglutitions produce peristaltic contractions, with pressure peaks of normal amplitude and duration, and if the LES pressure is normal and the LES shows complete relaxation, the manometric record is classified as IA, la.

If the manometric record of a patient shows some simultaneous contractions and pressure waves of high amplitude and long duration with some multi-peaked waves, and if the basal LES pressure is high and relaxations are normal, this manometric record would be classified as IIIB, 2a.

This classification is not a real classification of clinical disease entities. The clinical diagnosis is reached not only on the basis of manometry but also on data obtained by other investigations. For instance, typical achalasia will be IIc, 2b, but may also be IIa, 2b or (in case of vigorous achalasia) IIb, 2b. Diffuse esophageal spasm would be IIIB, 2a, but could also be III A, la.

The proposed classification system is expandable. For instance, vigorous contraction abnormalities can be subdivided on the basis of amplitude or duration of the pressure waves, or on the double- or multi-peaked nature of these waves.

The upper esophageal sphincter is not presently incorporated into the scheme. The qualitative evaluation of the striated muscle esophagus is described in the report of the manometric study.

The following scheme of classification of quantitative data is proposed :

	Region	Distal esophageal body		LES
	Consideration	Peristaltic performance	Contraction parameters	Basal pressure Relaxation
		I. No abnormality detected (100% peristaltic)	A. No abnormality detected	1. Normal a. Normal
	Classification	II. Aperistalsis (0 % peristaltic)	B. Vigorous contraction abnormalities*	2. High b. Incomplete
		III. Intermittent simultaneous	C. Low amplitude contractions	3. Low e. Other abnormalities
		contractions
		(1-99% peristaltic)
		IV. Other abnormalities	D. Other abnormalities	4. Other abnormalities

* Includes increased mean wave amplitude, prolonged wave durations, abnormal frequency of multi-peaked waves.