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What are the indications for 24-hour ambulatory pH and manometry measurement?
J.E. Richter (Cleveland)
The first report on ambulatory esophageal manometry was published in 1982 [1]. This technology using several pressure microtransducers spanning the esophageal body, allows ambulatory monitoring over prolonged periods of esophageal pressures as well as pH. Some years of experience with ambulatory esophageal manometry in the clinical setting have made it clear that the technique is a feasible one and that it provides valuable diagnostic information particularly in the non-cardiac chest pain syndrome, but also in patients with difficult to diagnose dysphagia and coughing spells.
The most important clinical indication for application of ambulatory manometry is in the evaluation of patients with non-cardiac chest pain. About half of these patients have demonstrable esophageal abnormalities, such as pathologic gastroesophageal reflux (GER), reflux esophagitis, or an esophageal motor abnormality. However, demonstration of reflux or dysmotility in a patient with chest pain merely points to the esophagus but does not prove the esophageal souce of pain, since many patients with similar abnormalities do not present with angina-like chest pain [2]. Only when pain episodes are found to coincide repeatedly with intermittent esophageal dysfunction is a cause-effect relationship most likely.
Table I summarizes the largest available studies using combined ambulatory manometry and pH to evaluate patients with non-cardiac chest pain [2-9]. Most notable is the findings that nearly 50% of patients have pathologic acid reflux with nearly 30% having acid reflux predictably associated with their chest pain episodes. In contrast, esophageal motility abnormalities were identified as a cause of chest pain on average in 13% of patients (range 0-28%). The most commonly identified motility abnormalities were frequent simultaneous contractions (spasm), aperistalsis or high amplitude contractions. This low yield of abnormal manometry suggests that ambulatory manometry should be reserved for the difficult to manage patient where standard manometry and provocative tests are unrevealing and trials of acid suppression and calcium channel blockers/anticholinergics have failed.
Other indications for combined manometry and pH monitoring may exist in patients with difficult to diagnosis dysphagia and coughing spells in whom acid reflux is suspected as a possible cause. For example, a recent study [10] found that patients with gastroesophageal reflux disease and nonobstructive dysphagia (normal esophagram and/or endoscopy) had an increased percentage of simultaneous wave activity during meal times compared to healthy controls. This motility abnormality was not identified on stationary manometry. In patients with acid suspected chronic cough [11], coughing spells can be easily recognized manometrically as phasic bursts of brief stimultaneous elevations in all intraesophageal pressure leads; thus the association with reflux, if present, can be assessed accurately.
References
1. Vantrappen G, Servaes J, Janssens J, et al. 24-hour esophageal pH-and pressure recordings in outpatients. In: Wienbeck M, ed. Motility of the digestive tract. New York: Raven Press, 1982:293-297.
2. Hewson EG, Dalton CB, Richter JE. Comparison of esophageal manometry, provocative testing, and ambulatory monitoring in patients with unexplained chest pain. Dig Dis Sci 1990;302-309.
3. Janssens J, Vantrappen G, Ghillebert G. 24-hour recording of esophageal pressure and pH in patients with noncardiac chest pain. Gastroenterology 1986;90:1978-1984.
4. Soffer EE, Scalabrini P, Wingate DL. Spontaneous noncardiac chest pain: value of ambulatory esophageal pH and motility monitoring. Dig Dis Sci 1989;34:1651-1655.
5. Ghillebert G, Janssens J, Vantrappen G, et al. Ambulatory 24-hour intraoesophageal pH and pressure recordings vs. provocative tests in the diagnosis of chest pain of oesophageal origin. Gut 1990;31:738-744.
6. Nevens F, Janssens J, Piessens J, et al. Prospective study on prevalence of esophageal chest pain in patients referred on an elective basis to a cardiac care unit for suspected myocardial ischemia. Dig Dis Sci 1991;36:229-235.
7. Lam GTH, Dekker W, Kan G, et al. Acute noncardiac chest pain in a coronary care unit. Evaluation by 24-hour pressure and pH recordings of the esophagus. Gastroenterology 1992;102:453-460.
8. Paterson WG, Abdollah H, Beck IT, DaCosta LR. Ambulatory esophageal manometry, pH-metry, and Holter ECG monitoring in patients with atypical chest pain. Dig Dis Sci 1993;38:795-802.
9. Voskuil JH, Cramer MJ, Breumelhof R, et al. Prevalence of esophageal disorders in patients with chest pain newly referred to the cardiologist. Chest 1996;109:1210-1214.
10. Singh S, Stein HJ, DeMeester TR, Hinder RA. Nonobstructive dysphagia in gastroesophageal reflux disease: a study with combined ambulatory pH and motility monitoring. Am J Gastroenterol 1992;87:562-567.
11. Paterson WG, Murat BW. Combined ambulatory esophageal manometry and dual-probe pH-metry in evaluation of patients with chronic unexplained cough. Dig Dis Sci 1994;39:1117-1125.
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