Role of stationary esophageal manometry in clinical practice. Manometric results
in patients with gastroesophageal reflux, dysphagia or non-cardiac chest pain

C. Ciriza de los Ríos, L. García Menéndez¹, A. Díez Hernández², M. Delgado Gómez², A. L. Fernández Eroles³,
A. Vega Fernández, A. I. San Sebastián and M. J. Romero Arauzo

Laboratory of Clinical Motility. Service of Gastroenterology. ¹Service of Clinical Analysis. ²Service of Endocrinology.
Research Unit. Hospital del Bierzo. León. ³Subdirección Médica de Servicios Centrales. Hospital de León. Spain

 

ABSTRACT

The present study was carried out to evaluate the diagnostic usefulness of stationary esophageal manometry in 263 patients divided into three groups: 150 patients with reflux symptoms, 68 with dysphagia, and 45 with non-cardiac chest pain. Patients with endoscopic abnormalities were excluded. Standard manometry was performed following the station pull-through technique. In the group of patients with reflux symptoms 40.7% had a normal manometry and 57.3% had abnormalities, being the most frequent (43%) hypotensive lower esophageal sphincter. In the dysphagia group, 20.6% of manometries were normal and 79.4% were abnormal, of which achalasia was the most frequent disorder (53.7%). In the case of non-cardiac chest pain, 42.2% of patients had a normal manometry and 57.8% an abnormal one, of which hypotensive lower esophageal sphincter was the most frequent abnormality. A significant higher proportion of manometric alterations were found in the dysphagia group compared to reflux symptoms and non-cardiac chest pain (p < 0.05). No statistical differences were found between the reflux and the non-cardiac chest pain groups.
Manometry yields a higher diagnostic value in patients with dysphagia, and therefore manometry should be performed routinely after the exclusion of any organic esophageal disease. Manometry is not a first-choice functional diagnostic test in the study of patirnts with gastroesophageal reflux or non-cardiac chest pain.

Key words: Stationary esophageal manometry. Dysphagia. GERD. Non-cardiac chest pain.

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Ciriza de los Ríos C, García Menéndez L, Díez Hernández A, Delgado Gómez M, Fernández Eroles AL, Vega Fernández A, San Sebastián AI, Romero Arauzo MJ. Role of stationary eso-phageal manometry in clinical practice. Manometric results in patients with gastroesophageal reflux, dysphagia or non-cardiac chest pain. Rev Esp Enferm Dig 2004; 96: 606-611.

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Recibido: 18-02-02.
Aceptado: 03-02-04.

Correspondencia: Constanza Ciriza de los Ríos. C/ Emiliano Barral, 13B. 4ºA. 28043 Madrid. Telfs: 915 191 382 - 987 455 200 ext (281). Fax: 987 455 300. e-mail: lgarcia@hbrz.sacyl.es

 

INTRODUCTION

Stationary manometry is the technique of choice to establish the diagnosis of primary esophageal motor disorders such as achalasia or diffuse esophageal spasm. AGA (American Gastroenterological Association) considers that it is also an indication for detecting esophageal motor abnormalities associated with systemic diseases such as connective tissue diseases, for the placement of intraluminal pH-metry devices, and for the preoperative assessment of peristaltic function before anti-reflux surgery. Manometry should not be routinely used as the initial test for chest pain or other esophageal symptoms, and is not an indication for the reaching or confirming a suspected diagnosis of esophageal reflux disease (1). However, stationary manometry might demonstrate abnormalities in the lower esophageal sphincter (LES) and in the esophageal body (EB) that contribute to the development of pathological gastroesophageal reflux disease (GERD) (2). The most frequent esophageal motor abnormality reported in patients with non-cardiac chest pain (NCP) is the nutcracker esophagus (3), and it has been demonstrated that patients with nutcracker esophagus have a consistent manometric diagnosis (4). For this reason, stationary manometry may be important to diagnose this subgroup of patients that usually experience a considerable delay in their diagnosis.

The aim of our study was to determine the diagnostic usefulness of stationary esophageal manometry in patients with reflux symptoms, dysphagia or NCP.

MATERIAL AND METHODS

Patients

In all, 263 patients (125 male and 128 female) with an age range of 16-91 years were studied. Patients were distributed into 3 groups: 150 patients with reflux symptoms (age range: 18-82 years), 68 with esophageal dysphagia as their main symptom with no other reflux symptoms associated (range age: 16-91 years), and 45 with NCP (range age: 29-76 years). All patients were examined by upper endoscopy and/or barium esophagogram to exclude any organic disease. Also, in all cases with NCP a cardiac disorder was excluded. A description of symptoms found in patients with reflux complaints is listed in tables I and II.

Stationary manometry

All patients were studied after 8-hour fasting. Medications known to affect esophageal motility were withheld for at least 72 hours, and proton pump inhibitors were withheld for at least seven days before the study. Standard esophageal manometry was performed following the station pull-through technique, advancing the catheter in 0.5 cm increments as described by Castell (5). A quadruple lumen polyvinyl catheter (inner diameter 0.8 mm, outer diameter 3.2 mm) with radially-oriented side ports spaced 5 cm apart was used (model, Symmed, Barcelona, Spain, S. L.). Each lumen was connected to an external transducer and perfused with distilled water at a constant rate of 0.6 mL/min from a low-compliance pneumohydraulic capillary infusion system (model, Symmed, Barcelona, Spain, S.L.). The equipment was connected to a PC polygraph (version 5.0. Synectics Medical, Stockholm, Sweden).

Statistical analysis

A Chi square test was used for statistical analysis of data. p < 0.05 was considered statistically significant.

RESULTS

Of the 150 patients with reflux symptoms, 61 (40.7%) had a normal manometry, 86 (57.3%) had abnormalities, and in 3 (2%) cases the exploration could not be completed. The alterations found were: hypotensive LES (resting pressure < 10 mmHg as measured from the gastric line to the end expiration pressure at the highest point) in 37 cases (43%); ineffective peristalsis in 33 cases (38.4%), of which 13 had also hypotensive LES; nonspecific hypercontractile pattern in 15 cases (17.4%), and a nutcracker esophagus in 1 (1.2%).

Of the 68 patients with dysphagia, 14 (20.6%) had a normal manometry and 54 (79.4%) abnormal results. The alterations found included: achalasia in 29 cases (53.7%); aperistalsis without achalasia criteria in 7 (13%); hypotensive LES in 5 (9.3%); hypertensive LES with resting pressure > 35 mmHg in 2 (3.7%); incomplete LES relaxation in 4 (7.4%); ineffective peristalsis in 4 (7.4%); nonspecific hypercontractile pattern in 2 (3.7%), and a nutcracker esophagus in 1 (1.8%).

Of the 45 patients with NCP, 19 (42.2%) had a normal manometry and 26 (57.8%) abnormal results. The following alterations found were: hypotensive LES in 14 cases (53.8%); nutcracker esophagus in 5 (19.2%); nonspecific hypercontractile pattern in 4 (15.4%), of which 2 had also hypotensive LES; ineffective peristalsis in 2 (7.7%), and hypertensive LES in 1 case (3.8%).

A higher proportion of manometric alterations were found in the dysphagia group compared to the GERD and NCP groups (p < 0.05). Significant statistical differences were not found between the GERD and NCP groups (Table III).

DISCUSSION

There is much controversy regarding the usefulness of manometry as a diagnostic tool to detect disorders of esophageal motility. Kahrilas et al. (1) claim that achalasia and diffuse esophageal spasm are the only clinically relevant motor disorders diagnosed by stationary manometry. However, other authors have demonstrated that manometric findings contributed to the clinical management of more than 20% of patients studied for non-cardiac chest pain, and more than 60% of patients studied for dysphagia (6). Our results are in agreement with the latter authors, as we found that in 79% of manometries performed for dysphagia abnormal results were obtained, and in almost 54% of them the diagnosis was achalasia. Also, in a high number of patients achalasia-specific alterations were found (aperistalsis, hypertensive LES, and incomplete LES relaxation) in the absence of achalasia criteria. In cases of NCP, we found manometric alterations in almost 58% of patients. We consider that this fact is significant since it has been demonstrated that when a heart disease is excluded and an esophageal source of the pain is considered, patients show a better acceptance of their symptoms and lifestyle (7). The most frequent motor disorder reported in Western countries in patients with NCP is nutcracker esophagus (3,4), but in Eastern countries nonspecific motor disorders are the most frequent finding (8,9). In our series, we found that the most frequent motor disorder in these patients was hypotensive LES (53.8%) compared to nutcracker esophagus (19%); hypotensive LES may contribute to gastroesophageal reflux, as previously described, and is the most common cause of non-cardiac chest pain (8,9).

Karhilas et al. (1) consider that clinically significant reflux is the common final pathway of a multifactorial pathophysiological process, some elements of which are evident manometrically. The most common manometric abnormalities related to reflux include hypotensive LES, short length of the intraabdominal part of LES, impaired peristalsis, increase in low-amplitude waves (8), or increase in transient relaxation (10). A defect in the triggering of secondary peristalsis has also been described (11). Leite et al. (12) described the alterations found in the wide category of nonspecific motor disorders, and they found that the most frequent abnormality was ineffective esophageal peristalsis, consisting of low amplitude contractions (< 30 mmHg) or non-transmitted contractions in 30% or more of water swallows. Recently, a new classification of motor disorders considering four patterns has been proposed, esophageal ineffective peristalsis being a motor disorder included within the hypocontractile pattern. Many patients formerly categorized as having nonspecific motor disorders would be included in this esophageal ineffective peristalsis group. This alteration is the most frequent manometric finding in patients with GERD (13,14). However, Karhilas et al. (1) concluded that the detection of any of these manometric abnormalities has not been shown to predict the occurrence of clinically significant gastroesophageal reflux. On the other hand, it has been demonstrated that the study of LES is of prognostic value for GERD cases, as a baseline pressure lower than 6 mmHg or a length of LES below 2 cm correlated with more severe disease and worse response to medical treatment (15). In our study, we found manometric alterations in 57% of patients with gastroesophageal reflux symptoms, and the most frequent findings were hypotensive LES (43%) and ineffective peristalsis (38%). Therefore, manometric alterations were found in a high number of patients and -although it is true that these alterations are not predictive for clinically significant reflux- we consider it important to point out that the information obtained may have some prognostic and therapeutic impact. Also, it has been explained that esophageal ineffective peristalsis is a hypocontractile motor disorder that is related to reflux.

In our study, manometry showed a higher diagnostic utility in patients with dysphagia compared to patients with GERD and NCP, since in cases with dysphagia a high number of manometric alterations were detected with a high proportion of achalasia among them. Also, many of the above-mentioned manometric alterations did not meet achalasia criteria but were closely related to it. Therefore, manometry should be routinely indicated for dysphagia cases once an organic origin of these symptoms has been ruled out by endoscopy or barium radiography.

We do not consider manometry as a first-choice functional diagnostic test in the study of GERD or NCP, but we do consider that it reveals important data such as a potential motor disorder associated with gastroesophageal reflux, or allows the esophageal origin of pain in NCP to be established.

REFERENCES

1. Kahrilas PJ, Clouse RE, Hogan WJ. An American Gastroenterological Association Medical position statement on the clinical use of esophageal manometry. Gastroenterology 1994; 107: 1865-84.        [ Links ]

2. Fiasse R. Intérêt des explorations autres que l'endoscopie et la pH-métrie oesophagiennes pour le diagnostic du reflux gastro-oesophagien de l'adulte. Gastroenterol Clin Biol 1999; 23: S31-6.        [ Links ]

3. Katz PO, Dalton CB, Ricther JE, Wu WC, Castell DO. Esophageal testing of patients with noncardiac chest pain or dysphagia. Results of three years' experience with 1161 patients. Ann Intern Med 1987; 106: 593-7.        [ Links ]

4. Basotti G, Fiorella S, Germani U, Roselli P, Battaglia E, Morelli A. The nutcracker esophagus: a late diagnostic yield notwithstanding chest pain and dysphagia. Dysphagia 1998; 13: 213-7.         [ Links ]

5. Castell JA, Dalton CB. Esophageal manometry. En: Castell DO ed. The Esophagus. Boston: Little Brown and Company, 1992. p. 143-60.        [ Links ]

6. Johnston PW, Johnston BT, Collins BJ, Collins JS, Love AH. Audit of the role of oesophageal manometry in clinical practice. Gut 1993; 34: 1158-61.        [ Links ]

7. Ward BW, Wu WC, Richter JE, Hackshaw BT, Castell DO. Long term follow-up of symptomatic status of patients with non-cardiac chest pain: is diagnosis of esophageal etiology helpful? Am J Gastroenterol 1987; 82: 215-8.        [ Links ]

8. Lau GKK, Hui WM, Lau CP, Hu WHC, Lai KC, Lam SK. Abnormal gastro-oesophageal reflux in Chinese with atypical chest pain. J Gastroenterol Hepatol 1996; 11: 775-9.        [ Links ]

9. Ho KY, NG WL, Kang JY, Yeoh KG. Gastroesophageal reflux disease is a common cause of noncardiac chest pain in a country with a low prevalence of reflux esophagitis. Dig Dis Sci 1998; 43(9): 1991-7.        [ Links ]

10. Dent J, Holloway RH. Esophageal motility and reflux testing. State of the art and clinical role in the twenty first century. Gastroenterol Clin N Am 1996; 25: 51-73.        [ Links ]

11. Mittal RK, Holloway RH, Penagini R, Blackshaw A, Dent J. Transient lower esophageal sphincter relaxation. Gastroenterology 1995; 109: 601-10.        [ Links ]

12. Leite LP, Johnston BT, Barrett J, Castell JA, Castell DO. Ineffective esophageal motility (IEM): the primary finding with nonspecific esophageal motor disorders. Dig Dis Sci 1997; 42: 1859-65.        [ Links ]

13. Spechler SJ, Castell DO. Classification of oesophageal motility abnomalities. Gut 2001; 49: 145-51.        [ Links ]

14. Richter JE. Oesophageal motility disorders. Lancet 2001; 358: 823-8.        [ Links ]

15. Campos GMR, Peters JH, DeMeesterTR, Öberg S, Crookes PF, Mason RJ. The pattern of esophageal acid exposure in gastroeophageal reflux disease influences the severity of the disease. Arch Surg 1999; 134: 882-7.        [ Links ]