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11 High-Resolution Esophageal Manometry with and…
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Fig. 11.18 Ineffective esophageal motility is dened by ≥50% ineffective
swallows (failed or weak—DCI<450mmHg-s-cm). Manometry in a patient
with severe GERD
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Multiple repetitive swallow (MRS) assessments
may be helpful in determining peristaltic reserve
(Fig.11.29).
Fragmented peristalsis: is dened as >50% of swallows
with a large break (>5cm) and not meeting criteria for
ineffective esophageal motility (DCI > 450)
(Fig.11.19).
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M. R. Youssef et al.
Fig. 11.19 Fragmented peristalsis: ≥50% fragmented contractions with
DCI>450mmHgs cm. Large breaks (>5cm in length) in the 20mmHg isobaric contour. In this HRM, there is a 6-cm break in the 20mmg isobaric
contour (consistent with a large break (>5cm)). Large peristaltic breaks could
be associated with delayed bolus clearance and higher acid exposure time
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High-Resolution Manometry withImpedance
(HRIM)
High-resolution impedance manometry (HRIM) has been introduced as a technique that combines the benets of HRM and
impedance-based bolus transit assessment. The combination of
HRM and multichannel intraluminal impedance (MII) provides
information regarding esophageal motility, bolus transit, and
esophageal clearance. This technology has demonstrated a good
correlation with video uoroscopy but does not have associated
radiation exposure [10]. HRIM was accomplished by adding multiple impedance electrodes on HRM catheters to facilitate the
measurement and display of impedance. The basic principles of
impedance are based on the measurement of resistance to the
electrical ow of the intraluminal contents. Impedance decreases
temporarily during the passage of a bolus due to its increased conductivity but returns to baseline when the bolus moves past each
pair of electrodes [11] (Figs.11.20, 11.21, and 11.22).
Fig. 11.20 Principles of intraluminal impedance monitoring: An alternating
current (AC) circuit is generated between two ring electrodes mounted on a
nonconductive catheter placed in a hollow organ such as the esophagus. Electrical impedance (Z ) of the electric eld between two electrodes is the ratio
between applied voltage (U ) and resulting current (I )
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Fig. 11.21 Bolus passage along a neighboring pair of electrodes yields a
typical impedance tracing, including ve phases: baseline impedance during
resting stage of the esophagus (phase 1); impedance rise caused by arrival and
passage of an air volume ahead of the bolus (phase 2); impedance drop and
recovery caused by arrival and passage of the bolus (phase 3); impedance rise
caused by wall contraction associated with lumen occlusion (phase 4) and
recovery of impedance signal to baseline levels during transition to resting
stage (phase 5)
M. R. Youssef et al.
Fig. 11.22 Impedance changes during swallowing and reux of a bolus,
detected by multichannel impedance monitoring. Proximal to distal progression of changes in impedance indicates antegrade bolus movement as seen
during swallowing, whereas distal to proximal progression indicates retrograde bolus movement, as seen during reux. LOS, lower esophageal sphincter
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HRIM could distinguish the intraluminal air, which exhibits
high impedance from liquid, which exhibits low impedance.
Impedance data from several pairs of electrodes can be integrated
using dedicated software and displayed superimposed on pressure
topography plots, thereby allowing visualization of the bolus as it
travels down the esophagus in conjunction with esophageal peristalsis (Fig.11.22).
HRIM has contributed signicantly to current metrics utilized
in the Chicago Classication. Measurements such as peristaltic
integrity at 20mmHg being adequate for bolus transit were determined with the use of HRIM.Peristaltic breaks (<2 cm) in the
20mmHg isobaric contour were associated with complete bolus
clearance by impedance criteria using HRIM; therefore, these
small breaks were demonstrated not to be pathognomonic for
abnormal bolus transit in subsequent studies [12]. Likewise, large
breaks (>5cm) in the 20 mmHg isobaric contour demonstrated
incomplete bolus transit on HRIM.Therefore, HRIM data contributed to the criteria developed for the diagnosis of fragmented
peristalsis and ineffective esophageal motility (IEM) in the newest Chicago Classication (version 3.0). Of note, the assessment
of impedance is not covered by the Chicago Classication of
esophageal motility disorders.
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Indications forHRIM
HRIM can be valuable in the differential diagnosis of disorders
resembling GERD. This includes behavioral disorders such as
rumination syndrome (unconscious postprandial abdominal musculature contractions that can return food back into the mouth), by
distinguishing rumination episodes from regurgitation or because
impedance sensors can detect gas movement. HRIM can detect
supragastric belching (where air rapidly enters and subsequently
exits the esophagus without reaching the stomach) from gastric
belching (diaphragmatic contractions forcing air into the esophagus, which can then be expelled) [13]. Furthermore, the combination of HRM with intraluminal impedance has been shown to
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discriminate reux episodes associated with TLESRs better than
those after swallow-induced LES relaxations [14].
HRIM has been used to characterize bolus transit in patients
with esophageal motor disorders and nonobstructive dysphagia.
This testing can diagnose whether a functional defect truly exists
in patients with dysphagia and other symptoms such as noncardiac chest pain, especially in patients with manometric diagnoses
of ineffective esophageal motility and diffuse esophageal spasm,
since it may identify a functional defect in approximately half of
these patients [15].
Studies suggest that, in patients with nonobstructive dysphagia
and normal manometry, impedance testing will identify a subset
of patients with impaired bolus transit [16]. In patients with achalasia, HRIM can be utilized to assess bolus retention in the esophagus and after therapy it can assess the adequacy of LES disruption.
However, in achalasia patients, low-baseline impedance levels
and air entrapment in the proximal esophagus limit the value of
intraluminal impedance monitoring as a test of esophageal emptying [17]. HRIM has also been used to evaluate post- fundoplication
dysphagia [18].
M. R. Youssef et al.
Technique
As previously described, the HRIM catheter is a solid state with
36 circumferential pressure sensors at 1-cm intervals and impedance measuring segments including 18 segments at 2-cm intervals (Medtronic Inc., Shoreview, MN). The catheter is also
placed transnasally and positioned to record from the hypopharynx to the stomach with approximately 2–3 intragastric sensors,
with the most distal impedance measuring segment at 5 cm
above the LES.
The HRIM protocol includes a ve-minute baseline recording
and then ten 5ml swallows of normal saline (better conductivity)
in a supine position for test swallows at 20- to 30-s intervals.
After placement, the supine patient is asked to take 10 liquid
(normal saline solution) and 10 viscous swallows.
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HRIM Interpretation
• Esophageal bolus clearance can be assessed by the measurement of bolus presence time (BPT) and total bolus transit time
(TBTT).
• BPT represents the time for the bolus to transverse completely
an individual recording segment and is measured at each
recording segment from the time the bolus enters the segment,
as indicated by a drop-in impedance to 50% of the baseline
value, until the bolus has cleared the segment, as evidenced by
the recovery of the impedance level to 50% of the baseline
value for ≥5s.
• TBTT represents the time for the bolus to transverse the whole
esophagus and is measured from the time the bolus enters the
proximal esophageal recording segment (Z1) until it has
cleared the most distal recording segment (Z4).
• Complete bolus transit if bolus entry occurs at the most proximal site and bolus exit points are recorded in all distal recording segments.
• Incomplete bolus transit if bolus exit is not identied at any of
the three distal recording segments.
• Based on the above denitions, normal individuals have a
complete bolus transit in at least 80% of liquid and at least
70% of viscous swallows [19]. Conversely, patients with more
than 20% of swallows with incomplete bolus transit for liquid
and more than 30% of swallows with incomplete bolus transit
for viscous are considered to have abnormal bolus transit for
liquid and viscous, respectively.
High-Resolution Manometry: Esophageal
Disorders Not Addressed by the“Chicago
Classication”
In clinical practice, there are a number of patients that have ndings
in HRM, which are not described by the Chicago classication. The
CC is a work in progress, and it is likely that future versions will
incorporate new categories of manometric abnormalities.
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M. R. Youssef et al.
1. Upper Esophageal Sphincter: Oropharyngeal dysphagia and
globus sensation could result from disorders of the upper
esophageal sphincter (UES). These symptoms demonstrate
impaired bolus transit from the hypopharynx into the esophagus. HRM evaluates mainly baseline pressures and relaxation
of the UES. Increased intrabolus pressure during swallows
may suggest either a cricopharyngeal bar (Fig. 11.23) or
Zenker’s diverticulum. In patients with cricopharyngeal bar,
the UES does not fully relax with a wet swallow because of a
thickening of the cricopharyngeal muscle. Of course, barium
esophagogram offers more sensitivity for the diagnosis of cricopharyngeal bar. There are no manometric criteria that could
help identify a Zenker’s diverticulum unless the diverticulum
is associated with a cricopharyngeal bar. HRM does not change
the management of patients with oropharyngeal dysphagia.
2. Hiatal Hernia: A hiatal hernia is the sliding of the stomach
into the chest cavity and is demonstrated in HRM as the separation between the diaphragmatic crura and the LES
(Fig. 11.24). The measurement of the distance between the
crura and the LES represents the size of the hiatal hernia.
Fig. 11.23 HRM demonstrating a cricopharyngeal bar. The white arrows
show raised intrabolus pressure
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Fig. 11.24 Hiatul hernia. Identication of a hiatul hernia. A 4-cm hiatus
hernia is identied in this HRM color contour. There are two zones of high
pressure in proximity to the gastroesophageal junction. One appears as a
horizontal band of green color about 43cm from the nares. This band of color
coincides with the pressure inversion point (PIP) (red line) that denes the
location of the diaphragm. The second zone of high pressure arises as a horizontal band of green color at the distal extent of the peristaltic pressure wave,
roughly at 38cm from the nares. A software tool that aids in identifying the
diaphragm (PIP) is shown. At the bottom of the gure, there are three horizontal, colored lines that are 1cm apart: blue at 41cm, red at 42 cm, and
green at 43cm from the nares. The white box near the middle of the contour
also displays three colored lines. These lines show the pressures recorded at
the positions of their corresponding colored lines at 41, 42, and 43cm from
the nares. The three colored lines at the bottom can be moved up and down as
a unit. They are positioned here to identify the location of the diaphragm
(PIP). Notice that with inspiration the blue line indicates a drop-in pressure
and the green line indicates a rise in pressure
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3. Hypotensive LES and Transient LES Relaxations
(TLESRs): Patients with hypotensive LES pressures are at
higher risk of developing GERD. However, the majority of
patients with GERD have normal LES pressure. In these
patients, relaxation of the LES not associated with swallowing
(TLESRs) (Fig. 11.25) is the most common mechanism of
GERD.
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M. R. Youssef et al.
Fig. 11.25 Transient lower esophageal sphincter relaxation (TLESR). This
study demonstrated the relaxation of the LES not associated with a wet swallow (WS) before the subject takes the WS
4. Rumination Syndrome and Belching: The diagnosis of
rumination is facilitated with the use of HRIM, which demonstrates an increase in intragastric pressure that eventually overcomes the LES pressure and results in retrograde movement of
gastric contents. The use of impedance helps differentiate
between gas and liquid gastric contents. In patients with intragastric belching, there is a similar increase in the intragastric
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