Is high resolution manometry enough or does multichannel intraluminal impedance still add information to esophageal function testing

Kshitij Kakar, MD, Leena Khaitan, MD

Department of Surgery, Case Western Reserve School Of Medicine

High resolution impedence manometry ( HRiM) is a comprehensive test of esophageal pressure and bolus transit (BT) dynamics. Standard manometry allowed assessment of the esophagus in 4 channels whereas high resolution manometry (HRM) has 32 channels, allowing a clearer assessment of esophageal function . Multichannel intraluminal impedance (MII) is established as a clear way to assess BT through the esophagus. This study was to assess whether impairments in BT seen on MII can also be more clearly assessed with HRM. In addition the level of impaired BT seen by MII was correlated with HRM findings.

METHODS: Consecutive HRiM studies done between June 2011 and August 2012 were reviewed retrospectively. Patients underwent 10 liquid and 10 viscous swallows when possible. Data collected included symptoms, diagnosis, medication use, and HRiM results of liquid and viscous swallows. Bolus transit was measured at 5, 10, 15 and 20cm above the gastroesophageal junction (GEJ). The initial level of impaired bolus exit for each swallow was recorded. Manometric breaks in each swallow by HRM were also recorded to assess for correlation. Patients with achalasia were excluded from analysis.

RESULTS: One hundred and ninety six patients (105 males and 95 females) underwent HRiM. (Age 18-93 yo). Some patients had more than one complaint. The most common diagnoses were normal manometry (48.9%), achalasia(22.9%), ineffective esophageal motility (11.2%) and non specific disorder (6.6%). 45 were excluded with achalasia. The most common presenting symptom was dysphagia in 124 patients (63.3%). Other symptoms included heartburn (28%), chest pain (18.8%) and GERD (21.9%). There were a total of 2813 swallows of which 1145 (40.7%) were not completely transmitted by impedance. Of these 24%, 36%, 27% and 12% did not exit at 20cm, 15cm, 10cm and 5 cm above the GEJ. Separating into liquid and viscous. there were 1440 total liquid swallows of which 561 (39%) were incompletely transmitted. Of this 22%, 39%, 28% and 11% did not exit at 20cm, 15cm, 10cm and 5cm above the GEJ. With regards to viscous swallows, there were 1373 in total of which 584 (42.5%) were not completely transmitted. The level of impairment was at 20cm (27%), 15cm (35%), 10cm (25%) and 5cm (13%)above the GEJ. 68 (45%) had normal transit for liquids and 63 (42%) for viscous, defined as > 70 % completely transmitted swallows. Impairments in BT did not correlate with any abnormalities in HRM. Manometric breaks were seen in 129 patients(85%) for at least one swallow. Breaks in manometry ranged anywhere from 5cm to 24 cm above the GEJ and did not correlate with the level of impaired BT.

CONCLUSION: High resolution manometry abnormalities do not correlate well with abnormalities on MII. When patients have abnormalities in BT, the most likely level is 15-20cm above the GEJ. This is at the level of the transition zone of striated to smooth muscle. This level of esophagus should be the level of future evaluation in the pathophysiology of motility disorders. At this time both impedance and HRM contribute to the evaluation of esophageal function.

Session: Poster Presentation

Program Number: P234

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