New Developments in Esophageal Motility Testing
- 132 Downloads
Purpose of review
The purpose of this review is to present the latest developments in esophageal motility testing and summarize the current paradigm of esophageal motility disorders.
While high-resolution esophageal pressure topography interpreted according to the Chicago Classification represents the gold standard to evaluate esophageal motility, recent studies highlight the additional value of novel manometric applications. Novel applications include provocative measures to assess for obstructive physiology at the esophagogastric junction (EGJ), esophageal peristaltic reserve, and rumination and supragastric belching disorders. Furthermore, high-resolution impedance manometry provides assessment of bolus flow in relation to pressure changes. Distinct from manometry, the endolumenal functional lumen imaging probe examines esophageal motor response to distension to provide complementary and alternative data with regard to EGJ function and esophageal body motor function. Barium esophagram with timed swallow and barium tablet continues to be an important esophageal motility test. Furthermore, current use of multichannel intraluminal impedance-pH monitoring extends beyond reflux monitoring to measure reflux clearance and esophageal epithelial integrity.
The diagnostic armamentarium for esophageal motility disorders has expanded tremendously to include a multitude of sophisticated tools. Advancements in diagnostic technology and understanding of esophageal physiology have shifted the field to more precisely characterize esophageal motility and guide phenotype-driven management.
KeywordsEsophageal manometry pH monitoring FLIP Mucosal impedance Barium esophagram Esophageal physiology EGJ obstruction
Functional luminal imaging probe
Multichannel intraluminal impedance-pH
Esophageal pressure topography
Integrated relaxation pressure
Lower esophageal sphincter
Per-oral endoscopy myotomy
American Gastroenterological Association
High-resolution impedance manometry
Esophageal impedance integral
Proton pump inhibitor
Repetitive antegrade contractions
Repetitive retrograde contractions
Mean nocturnal baseline impedance
Gastroesophageal reflux disease
Post-reflux swallow-induced peristaltic wave
RY, GTF, PMK: literature review, manuscript drafting, and final review.
Compliance with Ethical Standards
Conflict of Interest
Rena Yadlapati is a consultant for Ironwood Pharmaceuticals, Diversatek, and Medtronic, and received grants from NIHNIDDK and the American College of Gastroenterology.
Glenn Furuta reports grants from NIHNIDDK and personal fees from Shire, outside the submitted workIn addition; Dr. Furuta has a patent (EnteroTrack) licensed, and a patent (UpToDate) with royalties paid. Paul Menard-Katcher declares no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Disclosures/Declaration of Funding
RY: Consultant for Ironwood, Diversatek Healthcare, Medtronic; supported by NIH R01 DK092217 (Pandolfino), and ACG Junior Faculty Development Award (Yadlapati).
GTF: NIH 1K24DK100303, consultant for Shire, co-founder of EnteroTrack, royalties from UpToDate.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as • Of importance •• Of major importance
- 3.Roman S, Holloway R, Keller J, Herbella F, Zerbib F, Xiao Y, et al. Validation of criteria for the definition of transient lower esophageal sphincter relaxations using high-resolution manometry. Neurogastroenterol Motil. 2017;29(2).Google Scholar
- 5.•• Kahrilas PJ, Bredenoord AJ, Fox M, Gyawali CP, Roman S, Smout AJ, et al. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil. 2015;27(2):160–74 The Chicago Classification version 3.0 was developed by the International High Resolution Manometry Working Group and published in 2015. It is the current classification scheme for esophageal high-resolution manometry and has transformed the clinical diagnostic approach to esophageal motility disorders.CrossRefGoogle Scholar
- 6.•• Carlson DA, Ravi K, Kahrilas PJ, Gyawali CP, Bredenoord AJ, Castell DO, et al. Diagnosis of Esophageal Motility Disorders: Esophageal Pressure Topography vs. Conventional Line Tracing. Am J Gastroenterol. 2015;110(7):967–77 quiz 78. This prospective study highlighted the improved diagnostic accuracy and ease of interpretation using high-resolution manometry with esophageal pressure topography plots over conventional methods. This work emphasized the value of moving towards high-resolution manometry with esophageal pressure topography as the standard in esophageal manometry.CrossRefGoogle Scholar
- 8.Yadlapati R, Gawron AJ, Keswani RN, Bilimoria K, Castell DO, Dunbar KB, Gyawali CP, Jobe BA, Katz PO, Katzka DA, Lacy BE, Massey BT, Richter JE, Schnoll-Sussman F, Spechler SJ, Tatum R, Vela MF, Pandolfino JE Identification of quality measures for performance of and interpretation of data from esophageal manometry. Clin Gastroenterol Hepatol 2016;14(4):526–534 e1.Google Scholar
- 9.•Yadlapati R, Keswani RN, Ciolino JD, Grande DP, Listernick ZI, Carlson DA, et al. A system to assess the competency for interpretation of esophageal manometry identifies variation in learning curves. Clin Gastroenterol Hepatol. 2017;15(11):1708–1714.e3; This prospective study of 20 gastroenterology trainees identified that learning curves for high-resolution manometry vary, and that the volume-based cutoff of 50 cases is an inadequate surrogate for competency interpretation. This work springboarded subsequent efforts to standardize manometry interpretation training and assessment.Google Scholar
- 10.Yadlapati R, Keswani RN, Dunbar KB, Gawron AJ, Gyawali CP, Kahrilas PJ, et al. Benchmarks for the interpretation of esophageal high-resolution manometry. Neurogastroenterol Motil. 2016.Google Scholar
- 12.•• Hirano I, Pandolfino JE, Boeckxstaens GE. Functional lumen imaging probe for the management of esophageal disorders: expert review from the clinical practice updates committee of the AGA Institute. Clin Gastroenterol Hepatol. 2017;15(3):325–34 This paper is a current-day review of technical and diagnostic applications of the novel FLIP technology.CrossRefGoogle Scholar
- 14.•• Blonski W, Kumar A, Feldman J, Richter JE. Timed barium swallow: diagnostic role and predictive value in untreated achalasia, esophagogastric junction outflow obstruction, and non-achalasia dysphagia. Am J Gastroenterol. 2018;113(2):196–203 This retrospective cohort study found that barium timed swallow has good sensitivity and specificity for achalasia, and timed barium esophagram with a barium tablet increased diagnostic yield.CrossRefGoogle Scholar
- 16.•Marin I, Cisternas D, Abrao L, Lemme E, Bilder C, Ditaranto A, et al. Normal values of esophageal pressure responses to a rapid drink challenge test in healthy subjects: results of a multicenter study. Neurogastroenterol Motil. 2017;29(6) This prospective study of 105 heatlhy subjects identified normative manometric values in response to the rapid drink challenge test as a provocative maneuver to assess for outflow obstructive physiology at the EGJ.Google Scholar
- 18.Ang D, Hollenstein M, Misselwitz B, Knowles K, Wright J, Tucker E, et al. Rapid Drink Challenge in high-resolution manometry: an adjunctive test for detection of esophageal motility disorders. Neurogastroenterol Motil. 2017;29(1).Google Scholar
- 21.• Ang D, Misselwitz B, Hollenstein M, Knowles K, Wright J, Tucker E, et al. Diagnostic yield of high-resolution manometry with a solid test meal for clinically relevant, symptomatic oesophageal motility disorders: serial diagnostic study. Lancet Gastroenterol Hepatol. 2017;2(9):654–61 This study of 750 symptomatic patients found an increased diagnostic sensitivity of major motility disorders using high-resolution manometry when a solid test meal was used compared with ten single water swallows. These results support the incorporation of solid swallows into manometry protocols when assessing for symptomatic dysphagia.CrossRefGoogle Scholar
- 24.Carlson DA, Omari T, Lin Z, Rommel N, Starkey K, Kahrilas PJ, et al. High-resolution impedance manometry parameters enhance the esophageal motility evaluation in non-obstructive dysphagia patients without a major Chicago Classification motility disorder. Neurogastroenterol Motil. 2017;29(3).Google Scholar
- 25.•• Lin Z, Imam H, Nicodeme F, Carlson DA, Lin CY, Yim B, et al. Flow time through esophagogastric junction derived during high-resolution impedance-manometry studies: a novel parameter for assessing esophageal bolus transit. Am J Physiol Gastrointest Liver Physiol. 2014;307(2):G158–63 This study highlights the value of the trans-EGJ bolus flow time as a high-resolution impedance manometry measure of outflow obstruction across the EGJ in the evaluation of symptomatic dysphagia.CrossRefGoogle Scholar
- 29.Carlson DA, Kahrilas PJ, Ritter K, Lin Z, Pandolfino JE. Mechanisms of repetitive retrograde contractions in response to sustained esophageal distension: a study evaluating patients with postfundoplication dysphagia. Am J Physiol Gastrointest Liver Physiol. 2018;314(3):G334–G40.CrossRefGoogle Scholar
- 30.••Carlson DA, Kahrilas PJ, Lin Z, Hirano I, Gonsalves N, Listernick Z, et al. Evaluation of esophageal motility utilizing the functional lumen imaging probe. Am J Gastroenterol. 2016;111(12):1726–1735. This was one of the first papers to propose a FLIP topography motility classification scheme for esophageal motility. This study also reiterated that FLIP topography identifies abnormalities of EGJ relaxation that are not identified on manometry.Google Scholar
- 31.••Ponds FA, Bredenoord AJ, Kessing BF, Smout AJ. Esophagogastric junction distensibility identifies achalasia subgroup with manometrically normal esophagogastric junction relaxation. Neurogastroenterol Motil. 2017;29(1) In this study, EGJ distensibility using FLIP identified impaired distensibility in patients with clinical and radiological features of achalasia thought normal EGJ relaxation on manometry, and these patients responded well to achalasia treatment. Therefore, FLIP may have a complimentary role to manometry in assessment of EGJ relaxation.Google Scholar
- 35.Kahrilas PJ, Bredenoord AJ, Carlson DA, Pandolfino JE. Advances in management of esophageal motility disorders. Clin Gastroenterol Hepatol. 2018;16(11):1692–1700.Google Scholar
- 37.•• Khan MA, Kumbhari V, Ngamruengphong S, Ismail A, Chen YI, Chavez YH, et al. Is POEM the answer for management of spastic esophageal disorders? a systematic review and meta-analysis. Dig Dis Sci. 2017;62(1):35–44 This recent metanalysis of eight uncontrolled observational studies reported acceptable response rates of POEM in type III achalasia, distal esophageal spasm, and hypercontractile esophagus.CrossRefGoogle Scholar
- 39.Roman S, Gyawali CP, Savarino E, Yadlapati R, Zerbib F, Wu J, et al. Ambulatory reflux monitoring for diagnosis of gastro-esophageal reflux disease: update of the Porto consensus and recommendations from an international consensus group. Neurogastroenterol Motil. 2017;29(10):1–15.CrossRefGoogle Scholar
- 40.Frazzoni M, de Bortoli N, Frazzoni L, Tolone S, Furnari M, Martinucci I, et al. The added diagnostic value of postreflux swallow-induced peristaltic wave index and nocturnal baseline impedance in refractory reflux disease studied with on-therapy impedance-pH monitoring. Neurogastroenterol Motil. 2017;29(3).Google Scholar
- 45.Carlson DA, Crowell MD, Kimmel JN, Patel A, Gyawali CP, Hinchcliff M, et al. Loss of peristaltic reserve, determined by multiple rapid swallows, is the most frequent esophageal motility abnormality in patients with systemic sclerosis. Clin Gastroenterol Hepatol. 2016;14(10):1502–6.CrossRefGoogle Scholar