Esophageal manometry.docx
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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
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