Volume: The Esophagogastric Junction Chapter: Pressure measurements

Should the reproducibility of ambulatory esophageal manometry encourage more universal use of this technology?

R.M. Bremner, T.R. DeMeester (Los Angeles)

This question is probably best answered in two parts. Is ambulatory esophageal manometry clinically useful, and, if so, is it a reproducible test? Reproducibility alone should not encourage its diagnostic use. If the study is clinically useful, is reproducible, and can be performed easily with minimal discomfort to the patient, then the test should be considered for more widespread use.

Many studies have shown the benefit of ambulatory manometry as a diagnostic aid [1-3]. Early application in patients with non-cardiac chest pain showed an increased detection of motor abnormalities with prolonged monitoring although the yield of detection was still somewhat disappointing [4-8]. One of the reasons for this was that patients frequently did not have pain during the study. Application in patients with gastroesophageal reflux disease has shown a more profound motility defect than was realized with stationary manometry [9] Some patients have an inability to increase the amplitude and prevalence of peristalsis during meals. This has important implications when tailoring antireflux surgery to the motility abnormality, since performance of a full fundoplication in a patient with severe loss of contractility may result in post-operative dysphagia [10]. Ambulatory manometry has also clarified the diagnostic dilemmas that occur with motor disorders of the esophagus [11]. The technique has shown that patients with nutcracker esophagus, diffuse esophageal spasm, or a hypertensive lower esophageal sphincter, frequently are reclassified when monitored for a full circadian cycle. This may explain, in part, the disappointing results of medical and surgical therapy for these disorders. Prolonged monitoring also enables detection of episodic disorders which are frequently missed on stationary manometry. More recently we have found it has helped detect the specific motor abnormality responsible for dysphagia in patients with non-specific motor abnormalities on stationary manometry. It has also provided unique insight into the normal clearance mechanisms of the esophagus in response to naturally occurring reflux episodes [12-14].

There are two reports of repeated studies in normal volunteers which show that ambulatory manometry is reproducible [15, 16] Emde studied 24 healthy volunteers on two occasions 1-4 weeks apart and reported marked intraindividual reproducibility for amplitude and duration of contractions as well as for velocity of wave propagation [16]. Wang et al. found similar reproducibility when studying 10 healthy volunteers 2 weeks apart [15]. In fact, the coefficients of variation for the 10 motility parameters studied was less than for the simultaneous pH studies suggesting that ambulatory manometry is at least as reproducible as pH monitoring. The reproducibility suggests that contraction characteristics are stable over time. These studies noted a significant interindividual variation but we have recently found that this is less than for stationary manometry suggesting that analysis of the 1000 or more contraction waves from ambulatory manometry is more accurate than the 10 waves from stationary manometry.

Computer software programs that have been validated against manual analysis are now available for rapid automated analysis [17-19]. The test can be performed at the same time as pH monitoring with minimal extra discomfort to the patient [20]. The ease of use, the diagnostic information provided from circadian monitoring and the reproducibility of the test should encourage more widespread use of ambulatory esophageal manometry.

References

1. Smout AJPM, Breumelhof R. Combined 24-hour recording of esophageal pH and pressure. Dig Dis Sci 1991;36:98S-103S.

2. Stein HJ. Clinical use of ambulatory 24-hour esophageal motility monitoring in patients with primary esophageal motor disorders. Dysphagia 1993;8:105-111.

3. Breumelhof R, Smout AJ. The value of 24-hour combined esophageal pressure and pH recording in the detection of esophageal function abnormalities. Scand J Gastroenterol Suppl 1990;178:47-54.

4. Paterson WG, Abdollah H, Beck IT, Da Costa LR. Ambulatory esophageal manometry, pH-metry, and Holter ECG monitoring in patients with atypical chest pain. Dig Dis Sci 1993;38:795-802.

5. Peters L, Maas L, Petty D, et al. Spontaneous noncardiac chest pain. Evaluation by 24-hour ambulatory esophageal motility and pH monitoring. Gastroenterology 1988;94:878-886.

6. Breumelhof R, Nadorp JH, Akkermans LM, Smout AJ. Analysis of 24-hour esophageal pressure and pH data in unselected patients with noncardiac chest pain. Gastroenterology 1990;99:1257-1264.

7. Lam HG, Dekker W, Kan G, Breedijk M, Smout AJ. Acute noncardiac chest pain in a coronary care unit. Evaluation by 24-hour pressure and pH recording of the esophagus. Gastroenterology 1992;102:453-460.

8. Ghillebert G, Janssens J, Vantrappen G, Nevens F, Piessens J. Ambulatory 24 hour intraoesophageal pH and pressure recordings vs provocation tests in the diagnosis of chest pain of oesophageal origin. Gut 1990;31:738-744.

9. Stein HJ, Eypasch EP, DeMeester TR, Smyrk TC, Attwood SE. Circadian esophageal motor function in patients with gastroesophageal reflux disease. Surgery 1990;108:769-777;discussion 777-778.

10. Bremner RM, DeMeester TR, Crookes PF, et al. The effect of symptoms and nonspecific motility abnormalities on outcomes of surgical therapy for gastroesophageal reflux disease. J Thorac Cardiovasc Surg 1994;107:1244-1249;discussion 1249-1245.

11. Stein HJ, DeMeester TR. Evaluation of oesophageal motor disorders: 24-hour ambulatory oesophageal motility monitoring. Gastroenterol Int 1991;4:60-64.

12. Bremner RM, Hoeft SF, Costantini M, Crookes PF, Bremner CG, DeMeester TR. Pharyngeal swallowing: the major factor in clearance of esophageal reflux episodes. Ann Surg 1993;218:364-370.

13. Barham CP, Gotley DC, Mills A, Alderson D. Oesophageal acid clearance in patients with severe reflux oesophagitis. Br J Surg 1995;82:333-337.

14. Barham CP, Gotley DC, Miller R, Mills A, Alderson D. Pressure events surrounding oesophageal acid reflux episodes and acid clearance in ambulant healthy volunteers. Gut 1993;34:444-449.

15. Wang H, Beck IT, Paterson WG. Reproducibility and physiological characteristics of 24-hour ambulatory manometry/pH-metry. Am J Gastroenterol 1996;91:492-497.

16. Emde C, Armstrong D, Castiglione F, Cilluffo T, Riecken EO, Blum AL. Reproducibility of long-term ambulatory esophageal combined pH/manometry. Gastroenterology 1991;100:1630-1637.

17. Bremner RM, Costantini M, Hoeft SF, et al. Manual verification of computer analysis of 24-hour esophageal motility. Biomed Instrum Technol 1993;27:49-55.

18. Bumm R, Emde C, Armstrong D, Bauerfeind P, Blum AL. Ambulatory esophageal manometry: comparison of expert and computer-aided analyses. Gastrointest Motil 1990;2:216-222.

19. Emde C, Armstrong D, Bumm R, Kaufhold HJ, Rieken EO, Blum AL. Twenty-four hour continuous ambulatory measurement of oesophageal pH and pressure: a digital recording system and computer-aided manometry analysis. J Ambulatory Monitoring 1990;3:47-62.

20. Bremner RM, Costantini M, Crookes PF, et al. 24-hour pH and motility testing: Patient compliance and tolerance. Gastroenterology 1994;106:471.