Esophageal manometry.docx

Esophageal manometry.docx

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Esophagealmanometry

GIMotilityonline（2006）

Esophagealmanometry

RichardH.Holloway,B.Sc.（Med）,M.B.B.S.,M.D.,F.R.A.C.P.

KeyPoints

∙Esophagealmanometryremainsthegoldstandardfortheassessmentofesophagealmotoractivity.However,itisnotaprimaryinvestigationandshouldbeperformedonlywhenthediagnosishasnotbeenachievedbycarefulhistory,bariumradiology,orendoscopy.

∙Themostrewardingindicationforesophagealmanometryisdysphagia.

∙Therearetwomaintypesofmanometricrecordingsystems:

perfusedandsolidstate.Bothhavestrengthsandweaknesses,andthechoiceofanyparticularsystemdependsonhowthesestrengthsandweaknessesareviewed.

∙Optimalrecordingofeitherpharyngealoresophagealmotilityrequiresanarrayofmultiplerecordingpointsthatspanthewholeregionofinterestinordertoprovideanintegratedpictureofmotorfunction.

∙Performanceofaccurateandhigh-fidelitymanometricrecordingsrequiresathoroughunderstandingofhowthemanometricsystemoperatesaswellascarefulattentiontotechnique.Poor-qualityrecordingsinevitablyleadtoerroneousinterpretation.

∙Themajorelementsoftheanalysisofpharyngoesophagealmanometryarethedegreeofupperesophagealsphincterrelaxation,theintegrityofpharyngalperistalsis,andintraboluspressure.Themajorelementsoftheanalysisofesophagealmotorfunctionaretheintegrityofesophagealperistalsisandthedegreeofloweresophagealrelaxation.Astructuredandsystematicassessmentoftheseelementsshouldleadtoamanometricdiagnosis

∙Achalasia,diffuseesophagealspasm,andnonspecificmotordisordershavedistinctmanometricfeatures.

Introduction

Disorderedpharyngealandesophagealmotorfunctionisacommoncauseofsymptoms,particularlydysphagia,chestpain,andthoseassociatedwithgastroesophagealreflux.Motorfunctioncanbeassessedbyavarietyofrecordingtechniquesincludingradiology,scintigraphymanometry,andmostrecentlyintraluminalelectricalimpedancemonitoring.Someofthesearecomplementary.Thegoldstandard,however,fortheassessmentofmotordisordersremainsmanometry.Manometricmeasurementofesophagealpressureisthemostdirectmethodforassessmentofmotorfunction.Onlymanometrycangiveinformationonthestrengthofcontractions.Butmanometryalsohasitsdisadvantages.Inassessingtheconsequencesofmotility,themovementofintraluminalcontentisonlybyinference.However,whenthediagnosisrequiresinformationaboutintraluminalflow,thiscanbeobtainedbycomplementarymeasurementoftransitbyradiology,scintigraphy,orintraluminalimpedancemonitoring.

Overrecentyears,esophagealmanometryhasbecomearemarkablysophisticatedtechnique.Technicaladvanceshaveledtothedevelopmentofavarietyofrecordingequipmentandapproachestomanometricmeasurementsandtheiranalysis.Thedevelopmentofpowerfulcomputerizedacquisitionsystems,alongwithhigh-fidelitymultichannelperfusionpumpsandmanometriccatheters,hasenabledhigh-resolutionmeasurementanddisplayofesophagealmotility.

Performanceoftechnicallyadequatemanometricrecordingsandinterpretationofthefindingsrequiresconsiderablebackgroundknowledge.Therehavebeenfourtechnicalreportsonesophagealmanometry.1,2,3,4Thisreviewdescribestheprincipalelementsofthemanometricsystem,theapproachestothemeasurementsthemselves,theclinicalapplicationofthetechniques,andthemanometricfeaturesofcommonpharyngealandesophagealmotordisorders.

ManometricMethods

ManometricEquipment

Anumberofoptionsareavailablefortheperformanceofesophagealmanometry.Allarecapableofobtainingadequaterecordings,andthechoiceofanyparticularsystemdependsultimatelyonhowthesestrengthsandweaknessesareviewed.Therearetwomajorchoices:

systemsthatdependonassembliesthatincorporateintraluminalsolid-statetransducers,andthosethatuseperfusedassembliesconnectedtoexternaltransducers.Bothmethodswhenusedproperlygiveaccuratemeasurementsofesophagealpressures.However,onlyintraluminaltransducerscanrecordaccuratelytheamplitudeofpharyngealpressuresalthoughtheclinicalvalueofthesehasyettobedemonstrated.

PerfusedManometricSystems

Perfusedmanometricsystemsrelyonthetransmissionoftheintraluminalpressurestoexternalpressuretransducersalongmanometricassembliesperfusedusuallywithdistilledwater.5Theyhaveanumberofadvantagesoverassembliescomposedofintraluminaltransducers.Theycanreadilyincorporatealargenumber（currentlyupto21）ofrecordingpointsinordertoprovidehigh-resolutionpressurerecordings.6,7,8Theserecordingpointscanbearrangedinawidevarietyofconfigurationsthatcanbetailoredtospecificrecordingapplications,forexample,pharyngeal,esophageal,gastroduodenal,andanorectalmotilit