esophagus health

Esophageal Manometry by G.Bertelli

Generality

Esophageal manometry is an exam that evaluates the motility of the esophagus (at rest and during swallowing) and measures the pressure inside it.

The procedure requires the introduction of a small flexible probe through a nostril and throat up to the stomach. This maneuver can be slightly annoying, therefore, before the esophageal manometry, a local anesthetic (lidocaine-based spray) is administered. During the examination, the patient must be fasting and conscious, as he must cooperate and follow the instructions given by the doctor.

Esophageal manometry allows the diagnosis of any gastroesophageal reflux or other esophageal motility disorders responsible for dysphagia, heartburn, regurgitation or chest pain . The execution of this investigation is also indicated in case of suspected involvement of the esophagus during systemic diseases .

What's this

Esophageal manometry is a diagnostic investigation that allows:

  • Study the movements of the esophagus and the cardia (valve that separates the esophagus from the stomach), at rest and during swallowing;
  • Measure the pressure present inside the body of the esophagus (ie in the various sectors of its lumen) and at the upper and lower esophageal sphincters;
  • Establishing the effectiveness and coordination of propulsive movements in the act of swallowing;
  • Identify abnormal esophageal contractions.

Esophageal manometry is considered a functional and, as such, second-level examination . The survey is used, in fact, after performing other radiographic or endoscopic tests to establish the presence and extent of organic lesions on the esophagus.

With esophageal manometry it is possible to diagnose diseases that cause difficulty in swallowing, gastroesophageal reflux and / or dysfunctions in the movements of the esophagus (primitive or secondary to systemic diseases).

Anatomy of the esophagus (in short)

To better understand the purpose of esophageal manometry, it is necessary to remember some notions related to the structure of the esophagus .

  • The esophagus is a muscle-membranous duct, about 25-30 centimeters long and 2-3 cm wide, which connects the pharynx to the stomach . This structure is located almost entirely in the chest, in front of the spine.
  • The walls of the esophagus consist of a layer of epithelial lining similar to that of the mouth, while they are surrounded externally by two layers of smooth musculature. The esophageal mucosa is rich in mucus-producing glands, which has the function of lubricating the walls facilitating the passage of swallowed food .
  • By contracting in the act of swallowing, the esophageal muscular component pushes the food downwards, in the direction of the stomach, from which it is separated by a valve, called cardias, which prevents ingested foods and gastric juices from rising. In other words, after passing a food morsel, the esophagus contracts to advance it and the contraction wave propagates downwards.
  • Esophageal manometry allows us to record the characteristics of this wave (duration, amplitude and the way it propagates) and verify the function of the lower and upper esophageal sphincters (that is, how they relax and do so at the appropriate time). Numerous pathological conditions of the esophagus and esophageal sphincters are able to disturb the advancement of the food bolus at the moment of swallowing.

Why do you run

Esophageal manometry is a method that allows us to study the movements of the esophagus ( contraction and relaxation ) and to measure the pressure variations that occur within the various sectors (lower and upper) of its lumen.

The examination is indicated when the presence of an alteration of the physiological motility of the esophagus is suspected: this can result, from the symptomatic point of view, in acid reflux from the stomach, difficulty in swallowing or chest pain .

The pathologies that are diagnosed with esophageal manometry are, therefore, substantially:

  • achalasia;
  • Widespread esophageal spasm;
  • Non-specific motor disorders;
  • Motor pathology of the esophagus secondary to other diseases (such as systemic sclerosis);
  • Gastroesophageal reflux.

Esophageal manometry is also used to evaluate the functionality and anatomy of the esophagus, before some therapeutic procedures (eg anti-reflux surgery, pneumatic dilation for achalasia, etc.).

Esophageal manometry: when is it performed?

Esophageal manometry is generally prescribed to patients presenting:

  • Dysphagia, after excluding the existence of organic pathology of the esophagus and to formulate a diagnosis of esophageal motor pathology (achalasia, diffuse esophageal spasm etc.);
  • Chest pain excluding cardiopulmonary origin;
  • Retrosternal burning that could lead to suspect gastro-oesophageal reflux;
  • Systemic diseases (eg, collagen diseases, systemic sclerosis and neuromuscular pathologies) in which we want to establish the existence of an esophageal involvement (as in the case of multi-organ pathologies).

Exams associated with esophageal manometry

Esophageal manometry is a "second level" investigation, which is used after instrumental examinations such as:

  • EGDS (acronym of EsofagoGastroDuodenoScopia);
  • Esophagus radiographs and esophageal transit study (Rx-transit with contrast medium).

These investigations serve to exclude the existence of organic lesions against the esophagus or the esophagus-gastric joint, at the origin of the disorders reported by the patient.

Esophageal manometry is useful as a preliminary investigation to pH-metry (examination aimed at measuring the pH of the esophageal contents and the pressure inside the esophagus).

How to do it

  • Esophageal manometry consists of the registration of motor activity (contraction and relaxation) and of pressures inside the esophagus.
  • Esophageal manometry is performed by introducing a sterile and flexible tube, with a reduced size (diameter of about 4-5 mm). This device is gently introduced through a nostril to the stomach. Once properly positioned, the doctor performing the esophageal manometry starts the pump, then the probe is perfused by water .
  • To decrease the discomfort associated with the passage of the tube in the nose and throat, before the esophageal manometry, a local anesthetic spray (lidocaine) is given . In this regard, it is important for the patient to pre-empt any allergies to drugs or other substances.
  • During esophageal manometry, the patient is awake and conscious : anesthesia or sedation is not foreseen, as it is essential his collaboration for positioning the probe and carrying out the examination. The introduction of the device uses only a lubricating gel containing a local anesthetic (lidocaine).
  • Esophageal manometry involves the registration of the motor activity of the esophagus at rest and after swallowing small sips of water, when requested by the doctor. For this reason, the patient who undergoes esophageal manometry must be informed appropriately about the purposes and methods of the examination.
  • During the recording, which lasts about 20-30 minutes, the patient remains seated or lying on a couch and only needs to take deep breaths . At the beginning of the esophageal manometry, the doctor asks to exhale to register the pressure inside the stomach (this measurement will serve as a reference point for the following ones). Subsequently, the patient must perform some swallowing movements, to identify the wave of contraction that will travel the esophagus. The different pressures and propagation waves are recorded by the probe receptors and are transcribed on a graph thanks to an external transducer .
  • At the end of the esophageal manometry, the tube is slowly extracted and the patient can immediately return home. The doctor will inform you of the results of the examination after processing them.

Technical aspects

The probe used for esophageal manometry is formed by catheters (usually four or eight) very thin, each linked to a pump that ensures a constant flow of water. Along these tubes there are, at different levels and in variable numbers, some receptors, able to record the different measurements. In turn, the probe is connected to an external transducer.

In the course of esophageal manometry, the pressure present in the esophageal lumen is transmitted from the water column along each catheter to the transducer, which transforms the parameters detected into an electrical signal. The latter is then converted into a graph.

How long does esophageal manometry last?

The duration of the examination is variable: normally, for the execution of the esophageal manometry it takes approximately 20-30 minutes.

What does the report on esophageal manometry show?

In the report of the esophageal manometry, the diagnostic conclusion is reported, with the eventual iconographic documentation attached (graphs with pressure values).

Preparation

  • The patient must be fasting for at least 8 hours before the onset of esophageal manometry, to allow the success of the same. Feeding is allowed immediately after the completion of the exam.
  • In the 2-3 days before the scheduled date for the esophageal manometry, the patient must stop the use of drugs that influence the motility of the esophagus, such as, for example:
    • Calcium channel blockers: nifedipine, verapamil etc.
    • Prokinetics: metoclopramide, cisapride, domperidone, bromopride etc.
    • Anxiolytics: barbiturates, benzodiazepines etc.
  • The intake of other drugs can be continued before esophageal manometry; however, at the time of the visit prior to the exam, it is important to report any therapy in progress and agree any changes with the doctor.
  • On the day of the exam the patient must remember to present himself with all the documentation pertaining to the pathology (any reports of exams already performed, prescriptions of therapy, letters of discharge, etc.).
  • It is not necessary for the patient to be accompanied, as the examination does not involve the administration of drugs.

Contraindications and Risks

Esophageal manometry is a safe procedure. During the examination, the placement of the tube is not painful, but it can cause a slight sense of discomfort in the nose and throat, especially in the presence of adenoid hypertrophy and deviations of the nasal septum.

Possible effects when passing the probe

  • In the course of esophageal manometry, tearing, coughing, epistaxis, nausea and retching can sometimes occur; these symptoms subside following the directions given by the doctor.
  • Complications associated with esophageal manometry are very rare and include vagal or trigeminal seizures and perforation of a diverticulum.

Contraindications to esophageal manometry

To ensure that the patient does not present injuries to the digestive tract, particularly to the esophagus or to the stomach, the doctor always has an exogastroduodenal fibroscopy before the examination.

Contraindications to performing esophageal manometry may include:

  • Patients with altered mental state or blunting;
  • Patients who cannot understand or follow instructions;
  • Stenosis of the pharynx or upper esophagus (secondary, for example, to tumors);
  • Cardiac disorders in which vagal stimulation is contraindicated;
  • Serious and uncontrolled coagulopathies;
  • Presence of bubbles, varicose veins, diverticula or ulcers of the esophagus.

In these cases, the doctor will evaluate the possibility of postponing the exam or may opt for another diagnostic investigation.

Altered Values: Causes

The esophageal manomatria is able to quantify the contractile activity of the esophagus during swallowing.

This investigation is extremely useful for establishing the presence of alterations of esophageal peristalsis and of the function of the lower esophageal sphincter.

Pathologies diagnosed with esophageal manometry

The most common esophageal motility disorders, which can be diagnosed by esophageal manometry, include:

  • achalasia;
  • Widespread esophageal spasm;
  • Nutcracker gullet;
  • Dyskinesias of the non-specific esophagus (motility alterations with unidentified cause);
  • Eosinophilic esophagitis.

Esophageal motility can also be altered by systemic diseases such as:

  • Systemic sclerosis;
  • Chagas disease;
  • collagen;
  • Generalized disorders of neuromuscular function (eg myasthenia gravis, amyotrophic lateral sclerosis, stroke, Parkinson's disease);
  • Endocrine-metabolic diseases.

Upper esophagus manometry

The manometry of the upper part of the esophagus allows to distinguish swallowing disorders (dysphagia) from:

  • Primary disorders of the central nervous system;
  • Primary pharyngeal muscle diseases;
  • Dystopharyngeal muscle dystonia (upper esophageal sphincter).

Lower esophagus manometry

The manometry of the upper part of the esophagus serves to highlight the widespread esophageal spasm, achalasia or various lesions (cysts, tumors, nodules or diverticula) that can alter esophageal motility.