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Conventional esophageal manometry in clinical practice: Current impact of its use on patient management
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CLINRE-1016; No. of Pages 2
Clinics and Research in Hepatology and Gastroenterology (2017) xxx, xxx.e1—xxx.e2
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LETTER TO THE EDITOR Conventional esophageal manometry in clinical practice: Current impact of its use on patient management KEYWORDS Esophageal manometry; Achalasia; Manometry
To the Editor, Esophageal manometry is usually performed in the study of symptoms presumably associated with esophageal dysmotility [1]. The role of conventional manometry is being questioned since the advent of high resolution manometry, especially given its higher specificity [2]. However, the available data comparing both methods is scarce, and the high-resolution technology is considerably more expensive and still available only in referral centers [3]. As such, it becomes critical to understand the real current benefits, as well as the main limitations of conventional manometry in the study of patients with suspected or diagnosed esophageal motility pathologies [4]. This is particularly important in resource-limited settings where patient selection for high-resolution studies should be carefully weighted. In this context, it would particularly interesting to predict which patients will have a higher pre-test probability of obtaining changes in conventional manometry [5]. Given that, we tried to evaluate the clinical usefulness of conventional manometry in our medium-volume center, namely the ability to provide new information, diagnostic changes or to modify the therapeutic approach. Between January 2011 and May 2015, we performed 119 studies, mostly in women (62%), with a mean age of 53 ± 17 years, and patients followed for a mean time 22 ± 18 months. The average time between the onset of symptoms (present in 95%) and the exam was 32 ± 82 months. The most common symptoms included dysphagia (60%), regurgitation (28%), heartburn (21%), and chest pain (14%). In 20% of cases, the test was conducted in the context of known or suspected rheumatic
Figure 1
Diagnosis in conventional manometry.
diseases. Prior endoscopic evaluations were available in 80% of cases, in half of them (51%) without abnormalities. Manometry found abnormal results in 54% of cases, with the most common diagnoses being ineffective motility (45%) and achalasia (25%) manometry was inconclusive in 5% (Fig. 1). Manometry had an impact on subsequent management of patients in 70% of cases, providing additional information in 48% of cases (including new diagnoses in 33%), and consequent modification of the therapeutic approach 42%. Factors associated with the presence of new information included dysphagia (62% vs. 40.4%, P = 0.022), abnormal endoscopy (70.2% vs. 43.8%, P = 0.009), and abnormal esophagogram (93.3% vs. 18.2%, p <0.001). Factors associated with the impact of manometry include advanced age (55.8 vs. 47.8 years, P = 0.013), shorter duration of symptoms (24.7 vs. 49.9 months, P = 0.011), dysphagia (77.5% vs. 57.4%, P = 0.021) and abnormal esophagogram (93.3% vs. 63.6%, P = 0.017). Esophageal manometry is now commonly performed during the evaluation of patients with dysphagia, chest pain, and gastroesophageal reflux. Despite its limitations, conventional manometry is a more affordable procedure today, and still shows a high ability to modify the approach strategy of patients with esophageal symptoms, especially in cases of dysphagia accompanied by abnormalities in endoscopy and radiological studies. The data we report support the notion that although less sensitive and specific than high resolution manometry, conventional esophageal manometry can and should be used in a subgroup of patients where major changes may be suspected according to clinical data and
http://dx.doi.org/10.1016/j.clinre.2017.04.014 2210-7401/© 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Peixoto A, et al. Conventional esophageal manometry in clinical practice: Current impact of its use on patient management. Clin Res Hepatol Gastroenterol (2017), http://dx.doi.org/10.1016/j.clinre.2017.04.014
+Model CLINRE-1016; No. of Pages 2
ARTICLE IN PRESS
xxx.e2 findings in prior examinations, and thereby improve the costeffectiveness of using a more expensive and less available procedure such as high resolution manometry.
Disclosure of interest
Letter to the editor [4] Lacy BE, Paquette L, Robertson DJ, Kelley Jr ML, Weiss JE. The clinical utility of esophageal manometry. J Clin Gastroenterol 2009;43(9):809—15. [5] Lee CL, Wu CH, Chen TK, Tu TC. Esophageal manometry in patients with clinical symptoms mimicking esophageal origin: a hospital-based ten-year experience. J Chin Med Assoc 2003;66(1):27—32.
The authors declare that they have no competing interest.
References [1] Alrakawi A, Clouse RE. The changing use of esophageal manometry in clinical practice. Am J Gastroenterol 1998;93(12):2359—62. [2] van Hoeij FB, Bredenoord AJ. Clinical application of esophageal high-resolution manometry in the diagnosis of esophageal motility disorders. J Neurogastroenterol Motil 2016;22(1):6—13. [3] Savarino E, de Bortoli N, Bellini M, Galeazzi F, Ribolsi M, Salvador R, et al. Practice guidelines on the use of esophageal manometry - A GISMAD-SIGE-AIGO medical position statement. Dig Liver Dis 2016;48(10):1124—35.
Armando Peixoto ∗ Rui Morais Marco Silva Rosa Ramalho Guilherme Macedo Gastroenterology Department, Centro Hospitalar de São João, Oporto WGO Training Center, Porto Medical School—University of Porto, Alameda Prof. Hernâni Monteiro, 4200 Porto, Portugal ∗ Corresponding author. E-mail address: [email protected] (A. Peixoto)
Please cite this article in press as: Peixoto A, et al. Conventional esophageal manometry in clinical practice: Current impact of its use on patient management. Clin Res Hepatol Gastroenterol (2017), http://dx.doi.org/10.1016/j.clinre.2017.04.014
ARTICLE IN PRESS
CLINRE-1016; No. of Pages 2
Clinics and Research in Hepatology and Gastroenterology (2017) xxx, xxx.e1—xxx.e2
Available online at
ScienceDirect www.sciencedirect.com
LETTER TO THE EDITOR Conventional esophageal manometry in clinical practice: Current impact of its use on patient management KEYWORDS Esophageal manometry; Achalasia; Manometry
To the Editor, Esophageal manometry is usually performed in the study of symptoms presumably associated with esophageal dysmotility [1]. The role of conventional manometry is being questioned since the advent of high resolution manometry, especially given its higher specificity [2]. However, the available data comparing both methods is scarce, and the high-resolution technology is considerably more expensive and still available only in referral centers [3]. As such, it becomes critical to understand the real current benefits, as well as the main limitations of conventional manometry in the study of patients with suspected or diagnosed esophageal motility pathologies [4]. This is particularly important in resource-limited settings where patient selection for high-resolution studies should be carefully weighted. In this context, it would particularly interesting to predict which patients will have a higher pre-test probability of obtaining changes in conventional manometry [5]. Given that, we tried to evaluate the clinical usefulness of conventional manometry in our medium-volume center, namely the ability to provide new information, diagnostic changes or to modify the therapeutic approach. Between January 2011 and May 2015, we performed 119 studies, mostly in women (62%), with a mean age of 53 ± 17 years, and patients followed for a mean time 22 ± 18 months. The average time between the onset of symptoms (present in 95%) and the exam was 32 ± 82 months. The most common symptoms included dysphagia (60%), regurgitation (28%), heartburn (21%), and chest pain (14%). In 20% of cases, the test was conducted in the context of known or suspected rheumatic
Figure 1
Diagnosis in conventional manometry.
diseases. Prior endoscopic evaluations were available in 80% of cases, in half of them (51%) without abnormalities. Manometry found abnormal results in 54% of cases, with the most common diagnoses being ineffective motility (45%) and achalasia (25%) manometry was inconclusive in 5% (Fig. 1). Manometry had an impact on subsequent management of patients in 70% of cases, providing additional information in 48% of cases (including new diagnoses in 33%), and consequent modification of the therapeutic approach 42%. Factors associated with the presence of new information included dysphagia (62% vs. 40.4%, P = 0.022), abnormal endoscopy (70.2% vs. 43.8%, P = 0.009), and abnormal esophagogram (93.3% vs. 18.2%, p <0.001). Factors associated with the impact of manometry include advanced age (55.8 vs. 47.8 years, P = 0.013), shorter duration of symptoms (24.7 vs. 49.9 months, P = 0.011), dysphagia (77.5% vs. 57.4%, P = 0.021) and abnormal esophagogram (93.3% vs. 63.6%, P = 0.017). Esophageal manometry is now commonly performed during the evaluation of patients with dysphagia, chest pain, and gastroesophageal reflux. Despite its limitations, conventional manometry is a more affordable procedure today, and still shows a high ability to modify the approach strategy of patients with esophageal symptoms, especially in cases of dysphagia accompanied by abnormalities in endoscopy and radiological studies. The data we report support the notion that although less sensitive and specific than high resolution manometry, conventional esophageal manometry can and should be used in a subgroup of patients where major changes may be suspected according to clinical data and
http://dx.doi.org/10.1016/j.clinre.2017.04.014 2210-7401/© 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Peixoto A, et al. Conventional esophageal manometry in clinical practice: Current impact of its use on patient management. Clin Res Hepatol Gastroenterol (2017), http://dx.doi.org/10.1016/j.clinre.2017.04.014
+Model CLINRE-1016; No. of Pages 2
ARTICLE IN PRESS
xxx.e2 findings in prior examinations, and thereby improve the costeffectiveness of using a more expensive and less available procedure such as high resolution manometry.
Disclosure of interest
Letter to the editor [4] Lacy BE, Paquette L, Robertson DJ, Kelley Jr ML, Weiss JE. The clinical utility of esophageal manometry. J Clin Gastroenterol 2009;43(9):809—15. [5] Lee CL, Wu CH, Chen TK, Tu TC. Esophageal manometry in patients with clinical symptoms mimicking esophageal origin: a hospital-based ten-year experience. J Chin Med Assoc 2003;66(1):27—32.
The authors declare that they have no competing interest.
References [1] Alrakawi A, Clouse RE. The changing use of esophageal manometry in clinical practice. Am J Gastroenterol 1998;93(12):2359—62. [2] van Hoeij FB, Bredenoord AJ. Clinical application of esophageal high-resolution manometry in the diagnosis of esophageal motility disorders. J Neurogastroenterol Motil 2016;22(1):6—13. [3] Savarino E, de Bortoli N, Bellini M, Galeazzi F, Ribolsi M, Salvador R, et al. Practice guidelines on the use of esophageal manometry - A GISMAD-SIGE-AIGO medical position statement. Dig Liver Dis 2016;48(10):1124—35.
Armando Peixoto ∗ Rui Morais Marco Silva Rosa Ramalho Guilherme Macedo Gastroenterology Department, Centro Hospitalar de São João, Oporto WGO Training Center, Porto Medical School—University of Porto, Alameda Prof. Hernâni Monteiro, 4200 Porto, Portugal ∗ Corresponding author. E-mail address: [email protected] (A. Peixoto)
Please cite this article in press as: Peixoto A, et al. Conventional esophageal manometry in clinical practice: Current impact of its use on patient management. Clin Res Hepatol Gastroenterol (2017), http://dx.doi.org/10.1016/j.clinre.2017.04.014