Esophageal manometry is a diagnostic procedure used in the field of gastroenterology (gastrointestinal medicine) and to detect motility disorders (mobility disorders) of the esophagus. The basis for understanding this examination is knowledge of the mechanisms of the swallowing act. After the food pulp passes through the mouth and the occluded larynx, it is transported further into the esophagus (food pipe). The wall of the esophagus has both inner annular muscles and outer longitudinal muscles in its tunica muscularis (muscular coat of the organ wall). Contraction of the longitudinal musculature first dilates the lumen (opening) of the esophagus. Subsequently, contraction of the ring musculature prevents the food pulp from flowing back rostrally (toward the mouth). These muscle contractions are also called peristaltic waves and continue until the food pulp reaches the entrance of the stomach (cardia). Here, the final step required is the relaxation of the lower esophageal sphincter (lower sphincter), which in this sense is not an independent sphincter, but forms a functional unit of the surrounding diaphragmatic muscle loop (hiatal loop), the esophageal muscles, and the angle at which the esophagus enters the stomach. When this mechanism or motility is disturbed, a variety of symptoms such as dysphagia (dysphagia), reurgitation (reflux of food pulp), or pain (heartburn, noncardiac thoracic pain (chest pain) can occur. Esophageal manometry can be performed as a primary diagnostic test. For example, it is the gold standard in achalasia (relaxation disorder of the lower esophageal sphincter with subsequent dilatation of the preceding esophageal segment; so-called megaesophagus). But esophageal manometry can also be used as a supplement, e.g., in the case of reflux esophagitis (esophagitis as a result of food reflux from the stomach), following gastroscopy (ÖGD; esophagogastroscopy; gastroscopy) to find the cause. In addition, esophageal manometry serves as a placement aid for the pH probe used in 24-hour esophageal pH metry (pH measurement to diagnose reflux disease – reflux of acidic stomach contents into the esophagus) and is often performed in combination.
Indications (areas of application)
- Achalasia (relaxation disorder of the lower esophageal sphincter with subsequent dilatation of the preceding esophageal segment; so-called megaesophagus).
- Barett esophagus (metaplastic transformation of the epithelium of the esophagus in the lower esophageal area) – As a result of reflux esophagitis, here results in an increased risk (0.12-1.5% per patient year) for degeneration to adenocarcinoma (tumorigenesis).
- Boerhaave syndrome – rupture (tear) of the entire esophageal wall due to severe vomiting or coughing.
- Candidiasis of the esophagus (esophageal fungal infection).
- Dysphagia (dysphagia)
- Globus pharyngis syndrome – Subjective globus sensation (lump feeling), the cause of which (e.g., a tumor) cannot be objectified with the help of other diagnostics. Suspected cause is a dysfunction of the upper esophageal sphincter.
- Hiatal hernia (“diaphragmatic hernia”).
- Hypertensive esophagus – So-called “nutcracker” esophagus; motility disorder manifested by esophageal spasm (esophageal spasms) during the act of swallowing.
- Caustic burns
- Noncardiac chest pain (chest pain not caused by the heart).
- Peptic stenosis (narrowing of the esophagus due to reflux esophagitis).
- Postinterventional follow-up – e.g., after pneumatic dilation (dilatation of the esophagus by balloon catheter) or cardiomyotomy (splitting of the lower esophageal sphincter) for achalasia.
- Postoperative follow-up – e.g., after fundoplicatio (antireflux surgery) for reflux esophagitis.
- Esophagitis (esophagitis).
- Esophageal ectasia (abnormal dilation of the esophagus).
- Esophageal involvement in collagenoses (group of connective tissue diseases caused by autoimmune processes): systemic lupus erythematosus (SLE), polymyositis (PM) or dermatomyositis (DM), Sjögren’s syndrome (Sj), scleroderma (SSc) and Sharp syndrome (“mixed connective tissue disease”, MCTD).
- Acid burns
- Follow-up after drug therapy for motility disorders.
Contraindications
- Blood clotting disorders
- Taking anticoagulant medication – e.g., Marcumar.
Before the examination
Before the examination, a detailed internal medical history and a thorough physical examination are necessary to narrow down the diagnosis. Because this is an invasive examination method, the patient must be informed of the risks and informed consent must be obtained. Premedication, i.e., administration of medication prior to a medical procedure, is not usually performed. Pharyngeal anesthesia is also not used. The patient should be fasting 4-8 hours before manometry. The use of motility-influencing medications should be refrained from 48 hours before the examination; these include, for example:
- Beta-blockers (blood pressure medication).
- Calcium antagonists (blood pressure medication)
- Opiates (painkiller)
The procedure
Esophageal manometry is usually performed as an inpatient procedure. However, newer devices also allow it to be performed on an outpatient basis (at home) in the form of a long-term measurement. Perfusion manometry represents the conventional procedure. The patient is in the supine position during the manometry. For the examination, a water-perfused probe is advanced nasally (through the nose) through the esophagus into the stomach. The position is then checked by means of upper abdominal compression by the examining physician. The probe should now register an increase in pressure. If passage through the entrance to the stomach is not possible, as in achalasia, for example, the probe can be inserted endoscopically with the aid of a guide wire. Placement of the probe under X-ray control is also possible, but usually not necessary. First, a so-called pull-through manometry is performed: the probe is slowly pulled back out of the stomach and through the esophagus while the measuring points of the probe register the pressures (multipoint manometry). The contraction process (peristalsis) of the esophagus is then examined: For this purpose, the patient swallows water ten times, each time at intervals of 30 seconds. The pressure wave of the peristaltic muscle contraction is recorded. In addition, the flaccidity of the lower esophageal sphincter is examined during this phase of the examination, and the resting pressure in the esophagus is measured at the end.
After the examination
Following the examination, there are usually no special measures for the patient to observe. Depending on the results of the examination, medication or other therapeutic measures may need to be performed.
Possible complications
Insertion of the esophageal probe may be uncomfortable. Injury to the nasopharynx or esophageal mucosa is rare.
