1. Chhaya Hasyagar, MD Gastroenterology Kaiser, Sacramento
Esophageal Manometry
Chhaya Hasyagar, MD
Gastroenterology
Kaiser, Sacramento

2. Objectives Review esophageal anatomy
Role of esophageal manometry testing
Review manometry tracings

3. Anatomy 18- to 25-cm long muscular tube cervical and thoracic parts.
wall is composed of striated muscle in the upper part, smooth muscle in the lower part, and a mixture of the two in the middle.

4. Esophageal Motility Three separate stages: Voluntary or oral stage.
Pharyngeal stage.
Esophageal stage.

5. Esophageal Motility
The esophagus consists of two different parts. In humans, the cervical esophagus is composed of
striated muscles and the thoracic esophagus is composed of phasic smooth muscles. The striated
muscle esophagus is innervated by the lower motor neurons and peristalsis in this segment is due to
sequential activation of the motor neurons in the nucleus ambiguus. Both primary and secondary
peristaltic contractions are centrally mediated. The smooth muscle of esophagus is phasic in nature
and is innervated by intramural inhibitory (nitric oxide releasing) and excitatory (acetylcholine
releasing) neurons that receive inputs from separate sets of preganglionic neurons located in the
dorsal motor nucleus of vagus. The primary peristalsis in this segment involves both central and
peripheral mechanisms. The primary peristalsis consist of inhibition (called deglutitive inhibition)
followed by excitation. The secondary peristalsis is entirely due to peripheral mechanisms and also
involves inhibition followed by excitation. The lower esophageal sphincter (LES) is characterized
by tonic muscle that is different from the muscle of the esophageal body. The LES, like the esophageal
body smooth muscle, is also innervated by the inhibitory and excitatory neurons. The LES maintains
tonic closure due to its myogenic property. The LES tone is modulated by the inhibitory and the
excitatory nerves. Inhibitory nerves mediate LES relaxation and the excitatory nerves mediate reflex
contraction or rebound contraction of the LES. Clinical disorders of esophageal motility can be
classified on the basis of disorders of the inhibitory and excitatory innervations and the smooth
muscles.
Keywords

6. Esophagus Diagnostic procedures
Morphologic diagnostics
Esophageal radiography
Endoscopy
Pill cam ESO
Functional diagnostics
Esophageal manometry
Esophageal pH monitoring
Esophageal impedance
Radionuclide 99 mTC scintiscanning

7. Esophageal Manometry When does it help?
Functional disorder is suspected
Unrevealing morphological studies
Part of pre-operative evaluation

8. Water Perfused System

9. Water Perfused System Advantages Disadvantages Cost effective
Flexibility in configuration
Disadvantages
Slow response rate
Less suitable for UES and pharynx
Need for skilled personnel for use and maintenance

10. Solid state Catheters
Catheters have miniature strain gauge transducers built into the catheter to generate electrical output signals

11. Solid State Catheters Advantages Disadvantages Fast response
No water perfusion
Easy to use and calibrate
Disadvantages
Expensive
Limited number sensors
Fragile
Functional lifespan

12. Esophageal Manometry
Three steps:
LES
Body
UES

13. Esophageal Manometry

14. ManoScan™ / HRM Overview
Automatically captures all motor function from pharynx to stomach
Reduces data acquisition times by more than 60%
Simplifies procedures and technician training
Yields portable & reproducible data sets

15. Normal Study Using ManoScan™ Line Trace Mode
UES
LES

16. Normal study

17. Case 1 48 year old female with long standing heartburn
Symptoms well controlled on PPIs for 5 years
Now with recurrence of symptoms despite high dose PPI
EGD: hiatal hernia otherwise normal

18. Esophageal manometry 24 hour pH confirmed acid reflux
Proceeded with surgery for management of GERD

19. Case 2
36 year old archeologist with gradual onset of fatigue and dysphagia.
Difficulty with drinking water
Returned from a trip to the Amazon basin 6 months ago
EGD: Normal except for a “pop” felt while advancing scope into the stomach
Next step?

20. HREM
Aperistalsis in the smooth muscle portion of the body of the esophagus.
elevated resting LES pressure: >45 mmHg
incomplete LES relaxation after a swallow
“common channel effect”

21. Achalasia
Dilated esophagus
Bird beak appearance

22. Achalasia Idiopathic or acquired – Chagas disease
Increases risk of squamous cell CA
Chagas disease – parasite Trypanosoma cruzi, transmitted by “kissing bug”

23. Achalasia - Management
Endoscopic:
botulinum toxin injection of LES, pneumatic dilation of LES
Surgical:
Hellers myotomy (usually with anti-reflux fundoplication)

24. Case 3
50 year old female seen in the ER 4 times with sudden onset of chest pressure.
Cardiac workup including stress test was negative
EGD: normal
Next step?

25. Diffuse esophageal Spasm (DES)
Frequent simultaneous contractions (>20-30%) with interval normal contractions.
Confined distal 2/3.
Multiphasic waves.
Prolonged duration.
Spontaneous contractions
High amplitude of the contractions

26. DES Rosary Bead or corkscrew esophagus Treatment: CCB (diltiazem)
nitrates (isosorbide)
Sildenafil
TCA (imipramine)

27. Nutcracker Esophagus
high amplitude peristaltic contractions in the distal 10 cm of the esophagus
average distal esophageal peristaltic pressures >220 mmHg
Increased distal peristaltic duration (mean value >6 sec)

28. Case 4
55 year old female with intolerance to cold, heartburn not responding to medications, with c/o dysphagia to solids for 8 months
Wears gloves in summer as her fingers turn blue to purple in AC rooms
Upper endoscopy: normal, no webs or rings
Next step?

29. Scleroderma Pathophysiology:
alterations of the microvasculature, the autonomic nervous system, and the immune system, leading to fibrosis
Affects lower 2/3 of esophagus

30. Esophageal impedance
Measures changes in resistance to alternating electrical current when a bolus passes through a ring
Liquid containing boluses will lower the impedance to a nadir value
Gas will produce a rapid rise in impedance

31. Esophageal Impedance

32. Esophageal motility disorders
Primary disorders
Achalasia
Diffuse esophageal spasm
Nutcracker esophagus
Ineffective motility disorder
Secondary disorders
Scleroderma

33. Disclosure: none
Questions