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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.
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