High Resolution Manometry – an underappreciated tool for examination of dysphagia in a surgical setting.

Jonas S Jensen, MD, Jan M Krzak, MD, Lars Stig Jorgensen, MD. Lillebaelt Hospital, Kolding, Denmark

Introduction: Examination of dysphagia in Danish surgical departments, rely primarily on upper gastrointestinal endoscopy. When no visible or histological cause can be detected, esophageal motility disorders are important differential diagnosis. In examining these disorders and in evaluating gastroesophageal reflux disorder (GERD), High Resolution Esophageal Manometry (HRM), provide valuable insights.

The purpose of this study was to examine referrals and final diagnosis from HRM in a surgical center specializing in esophageal disorders.

Methods and Procedures: All patients referred to HRM at our surgical center were included in the study and HRM was performed from September 2013 to June 2015. All patients had previously undergone upper gastrointestinal endoscopy at our center or the referring department. All procedures were performed using InSIGHT™ HRiM® and accompanying software (Sandhill Scientific, Colorado, USA) and graded according to the Chicago-classification. Referring department, referral-diagnosis, demographics and final HRM-diagnosis were prospectively collected and analyzed.

Results: 438 patients were referred to HRM, primarily from our own department (N=350, 79,9%), other departments in our hospital (N=12 2,7%), private practice (N=20, 4,6%) and departments at other hospitals (N=56 12,8%).

Of the 390 procedures performed, the referral-diagnosis was motility disorder (n=161, 41,3%) and GERD (n=229, 58,7%). The mean age was 50,4±17,0 years (rage 16-86 years) with 58,5% female and 41,5% male. There were no significant differences in age or sex when comparing the two groups.

Pathological findings were present in 197 cases. There was no difference in frequency of pathological findings stratified for referral-diagnosis (p=0.11). Patients referred with suspicion of motility disorder had a significantly higher frequency of abnormal bolus transit (p=0.02), achalasia (p<0.01) as well as EGJ-outlet obstruction and pseudo achalasia (p<0.01). Patients referred as part of investigation of GERD, had a significantly higher frequency of weak/ineffective motility (p=0.02). There was no difference in frequency of nutcracker/jackhammer esophagus between the two groups (p=0.035)

At our surgical center, the rate of HRM per upper gastrointestinal endoscopy was 4,4% based on 8031 endoscopies. A similar surgical centre in our area had, based on referral to our center, a HRM to endoscopy rate of 0.1% based on 10419 endoscopies.

Conclusion: HRM is an important diagnostic tool and supplements upper gastrointestinal endoscopy in examination of dysphagia as well as GERD, with significant differences in patterns of motility disorders. Knowledge and availability of HRM increases use at a surgical center, yielding better diagnostics of patients with suspected motility disorders. 

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