View pointHigh-resolution manometry: A new gold standard to diagnose esophageal dysmotility?Manométrie haute résolution : nouvel examen de référence pour le diagnostic des troubles de la motricité œsophagienne ?
Introduction
Esophageal manometry is considered the gold standard for the assessment of esophageal motility after mechanical obstruction and mucosal disease have been excluded by endoscopy. The conventional technique uses a probe with four to eight variably spaced pressure sensors positioned in the esophageal lumen to monitor pressure changes during swallowing. During the study the probe may need to be repositioned to examine the entire esophagus and to focus on a particular area of interest.
Esophageal high-resolution manometry (HRM) was first described by Clouse et al. in the 1990s [1]. This technique is characterized by an increased number of pressure sensors (21 to 36 one-centimeter spaced sensors) spaced closely together (< 1–2 cm apart). Thus esophageal intraluminal pressure can be more completely defined from the hypopharynx to the proximal stomach with minimal spatial gaps between recordings sites and with minimal movement related artifacts [2]. More recently, the introduction of solid-state high fidelity sensors allows pressure measurements all around the whole esophageal circumference [3].
Data from HRM can be illustrated in the context of esophageal pressure topography (EPT) plots by defining pressure domains with isobaric conditions. The pressure topography plots utilize color to separate the pressure domains and this information can be leveraged to clearly identify the esophagogastric junction (EGJ) and the functional anatomy of the esophagus (Fig. 1). Moreover, the diagnostic yield may be increased especially in cases of dysphagia. Finally technical improvements coupled with pressure topography analysis should simplify esophageal manometric exploration and the interpretation of esophageal motor dysfunction.
Section snippets
A better assessment of esogastric junction?
HRM defines EGJ morphology and location more accurately than conventional low-resolution manometry [2]. Despite the respiratory and swallowing-induced EGJ mobility, the borders of EGJ are easily recognized with EPT plots and the relative positions of the crural diaphragm and the lower esophageal sphincter (LES) are identified. A separation of these two EGJ components by more than 2 cm defines manometric hiatal hernia [4] (Fig. 2).
Esophageal HRM may also improve the accuracy and consistency of
An improved diagnostic yield for dysphagia?
According to experts the increased yield of HRM compared to conventional manometry is 12–20% in patients with dysphagia [5]. Cases that can be identified only by HRM include functional EGJ obstruction [8] as discussed above, esophageal peristaltic defects associated with proximal bolus transit abnormalities (transition zone defects [9], [10]) and abnormal pharyngeal and upper esophageal sphincter (UES) function [11].
Practical advantages in clinical practice
The positioning of the probe is facilitated because UES and EGJ are easily recognized. Moreover HRM doesn’t require the time-consuming and poorly tolerated pull trough technique. Therefore the required procedure time is decreased. These features ensure that HRM can be performed by relatively inexperienced staff without affecting the quality of the examination.
Examinations can easily be performed in an upright and sitting position with solid-state sensors HRM as opposed to perfused manometry
Esophageal high-resolution manometry: a new gold standard?
HRM is an essential tool for mechanistic studies of esophageal function in research. Transient LES relaxations (tLESr), the most important mechanism of gastro-esophageal reflux disease, are easily identified. Pandolfino et al. used HRM to demonstrate that esophageal shortening and crural diaphragm inhibition always preceded EGJ opening and common cavity in case of tLESr [22]. Moreover, the effects of pharmacological agents on different esophageal segments were clarified thanks to HRM [9], [23].
Conflict of interest
None.
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