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Pharyngeal Manometry 319
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These findings suggested that the cricopharyngeal
indentation is due to weak constrictors with outpouching of the gullet above and below the cricopharyngeal muscle. The cricopharyngeal muscle
showed no abnormalities in terms of resting pressure, relaxation, and contraction pressure. Furthermore, there was no significant difference in
intrabolus pressure, neither above nor at the level of
the cricopharyngeal muscle.
6 Simultaneous Examination
The combination of simultaneous videoradiography
and intraluminal manometry provides fluoroscopic
control of sensor positioning and allows pressure
recording and analysis with respect to bolus transport.
It combines movement analysis with pressure
recordings.
When solid-state sensors are used, the technique
can be performed with the patient in an upright,
physiologic position and comfortably seated without
the discomfort of swallowing in a supine position and
without the discomfort of the continuous flow of
perfused manometry (Fig. 3).
The history of simultaneous examinations goes
back to 1995 when Fyke and Code (1955) measured
pharyngeal pressure with a microtip transducer fitted
on a gastric tube. They used simultaneous cineradiography, but the manometric recordings were made
with a galvanometer and a polygraph. Atkinson et al.
(1957) took rapid serial radiographs during pharyngeal
manometry with a perfused technique. Sokol et al.
(1966) reported their experience with simultaneous
cineradiography and perfused intraluminal manometry
of the pharynx.
Isberg et al. (1985) reported solid-state manometry
with Gaeltec sensors and simultaneous cineradiography. They studied movement of the upper esophageal
sphincter and the manometric device in nine healthy
volunteers. They found an upward movement of the
manometry catheter that correlated with the elevation
of the soft palate. The pressure was recorded on a
polygraph.
Mendelsohn and McConnel (1987) described a
simultaneous technique with perfused manometry and
McConnel et al. (1988) and also Cerenko et al. (1989)
described simultaneous fluoroscopy and solid-state
Fig. 3 Simultaneous videoradiography and solid-state intralu-
minal manometry during barium swallow. The pressure registration is displayed on the video screen and is also registered on
the computer. Thesubject is comfortably seated andfluoroscopy
is performed in a lateral projection
manometry. McConnel et al. called the technique
‘‘manofluorography.’’
Jacob et al. (1989) used solid-state manometry and
simultaneous videoradiography with polygraph
recording to study the upper esophageal sphincter in
eight volunteers. This was a thorough study of upper
esophageal sphincter opening and volume-dependent
variables such as intrabolus pressure and opening
duration.
In the same year, Cook et al. (1989) described the
simultaneous technique in two studies involving
healthy volunteers. They used solid-state sensors but a
conventional eight-channel polygraph. This was a
study of the upper esophageal sphincter where they
concluded that upper esophageal sphincter opening
involves sphincter relaxation, anterior laryngeal traction, and intrabolus pressure. They also found volume-dependent changes in upper esophageal
sphincter dimensions and upper esophageal sphincter
timing indicating a sensory feedback mechanism
generated by the brainstem swallow centers.
The following year, Dantas et al. (1990) used the
technique in six patients with cricopharyngeal bars.
They found normal contact pressures in the pharynx
but increased upstream intrabolus pressure. They also
studied different bolus variables with this technique
(Dantas et al. 1989).
A high-density barium preparation increased the
intrabolus pressure as well as the upper esophageal
sphincter opening duration and anterior hyoid movement. All these studies used the Gaeltec solid-state
320 R. Olsson
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catheter but recording was with an ordinary polygraph
without computerized analysis.
7 Conclusion
Shaker et al. (1992) used the perfused sleeve
device concurrent with videoradiography to study the
esophagoglottal closure reflex. They concluded that
esophageal distension by air or balloon evokes a
glottal closure mechanism, suggesting the existence
of an esophagoglottal reflex.
Ren et al. (1993) used perfused manometry concurrent with videofluoroscopy in a study of intrabolus
pressure and concluded that intrabolus pressure can
serve as an indicator of the forces resisting peristaltic
transport. They called the technique ‘‘videofluoromanometry.’’ Ergun et al. (1993) used the simultaneous
technique in eight volunteers. They argued strongly for
Simultaneous videoradiography and pharyngeal solidstate manometry provides qualitative and quantitative
information by assessing bolus transport and intraluminal pharyngeal pressures combined. It can be performed with the subject seated in an upright
physiologic swallowing position during fluoroscopy
in a gastrointestinal radiology laboratory.
Our experience is that the most complete understanding of bolus transport requires both manometric
and radiographic input and that concurrent radiography and manometry will play a more prominent role
in the future.
the use of fluoroscopic sensor positioning when performing pharyngeal timing studies. They used solidstate sensors and video recording but polygraph
registration without a computer. Dejaeger et al. (1994)
References
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with pharyngeal dysphagia but a normal barium
swallow and compared them with normal volunteers
(Olsson et al. 1995a, b). The patient group showed
statistically significant differences for eight of ten
manometric variables. We found manometric abnormalities that might contribute to dysphagia: five with
high upper esophageal sphincter resting pressure, five
with high upperesophageal sphincter residualpressure,
three with weak pharyngeal contractions, seven with
prolonged contraction/relaxation time, and seven with
incoordination. The conclusion of this study was that
manometry couldprovide additionalinformation inthe
diagnosis of dysphagic patients.
We have also studied patients with penetration of
barium intothe larynxduring swallowing(Olsson et al.
1998). Videomanometry revealed an increased fre-
quency of manometric abnormalities in patients with
penetration. There was, however, no specific finding
and a multitude of abnormalities were found with no
association between manometric abnormalities and the
degree of barium penetration.
In patients with pharyngeal retention we found a
significantly lower laryngeal elevation, indicating the
importance of pharyngeal shortening in the swallowing sequence (Olsson et al. 1997).
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Esophageal Manometry
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and Gastroesophageal Reflux Monitoring
Karin Aksglæde, Per Thommesen, and Peter Funch-Jensen
Contents
1 Esophageal Manometry .......................................... 323
1.1 Technique................................................................... 324
1.2 Manometric Findings................................................. 324
1.3 Clinical Interpretation................................................ 324
2 Gastroesophageal Reflux Monitoring.................... 325
2.1 Technique................................................................... 325
2.2 Diet and Drugs While Performing the Study........... 327
2.3 Evaluation of GER Monitoring................................. 327
References.......................................................................... 327
K. Aksglæde (&) P. Thommesen P. Funch-Jensen
Division for Gastrointestinal Motility Disorders,
Department of Radiology, Aarhus University Hospital,
Nørrebrogade 44, Aarhus, Aarhus C 8000, Denmark
e-mail: kariaksg@rm.dk
P. Funch-Jensen
Aleris-Hamlet Hospital, and Clinical Institute,
Aarhus University, Aarhus, Aarhus C, Denmark
Abstract
Manometry and gastroesophageal reflux (GER)
monitoring are important tests in evaluation of
patients suspected of having motility disorders and/
or gastroesophageal reflux disease (GERD), but we
do not recommend these as first choice investigations. If a functional, benign esophageal disease is
suspected, a video-radiologic investigation basedon
physiological principles using bread-and-barium
could often separate patients with normal manometry from patients with severe motility disorders,
i.e., diffuse esophageal spasms (DES) and achalasia
(Nellemann et al. 2000). Furthermore, this radiologic method could demonstrate GER in adults with
a sensitivity of 52 % and aspecificity of100 %, thus
reducing the number of patients referred to manometry and GER monitoring (Aksglæde et al. 1999).
1 Esophageal Manometry
Manometry is used to measure intraluminal pressure
and pressure changes in the esophagus generated by
contractions in the circular muscles. Esophageal
manometry can be used in patients with suspected
primary or secondary motility disorders. Secondary
esophageal motility disorders are those occurring in
patients having a generalized or systemic disease, i.e.,
systemic sclerosis or diabetes mellitus. Furthermore,
manometry is used preoperatively before fundoplication (Kahrilas et al. 1994).
In difficult diagnostic cases an approach with
combined video-radiology and manometry is often
useful.
O. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnostic Imaging, DOI: 10.1007/174_2012_655,
Ó Springer-Verlag Berlin Heidelberg 2012
323
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1.1 Technique
Esophageal pressures are measured directly with solidstate transducers, or indirectly with external transducers
connected to a water-perfused system. The solid-state
system measures pressures independently of body position and requires no external water supply and pumps,
thus makingit advantageous in long-terminvestigations.
The pressure catheter used for conventional esophageal manometry contains 3–8 pressure channels spaced
B5 cm. The catheter is introduced through a nostril and
guided into the stomach, and then retracted through the
loweresophagealsphincter(LES) ata rateof0.5–1.0 cm/
s (‘‘rapid pull-through technique’’) to measuretheresting
lower esophageal sphincter pressure (LESP) in proportion to the fundic pressure. The relaxation is best measured using the ‘‘station pull-through technique’’, where
the probe is pulled through the LES at 0.5–1.0 cm at a
time until recordings become stable, and relaxation is
determined by wet or dry swallows. Finally, it is placed
with the distal channel 2–5 cm above the LES and a
manometric study of the esophageal body is performed.
Pressure amplitude, velocity, and duration of contractions are registered after dry, wet, and solid swallows.
(Keren et al. 1992). Furthermore, the intra-esophageal
baseline pressure can be determined during continuous
swallowing. Measurement of the relaxationof the LES is
not always easy, but a gradual increase in baseline
pressure during swill is seen in patients with incomplete
opening of the LES (Funch-Jensen et al. 2000).
A newer manometric methodology called high-resolution manometry (HRM) has been introduced recently.
The catheterusedcontains 22–36 pressurechannelsspaced
at B2 cm intervals. The catheter is passed transnasallyand
positioned with recording sites from hypopharynx to the
stomach. The catheter remains in this position during the
examination, thereby eliminating movement artifacts.
Advanced analysis software displays the measurements
into color pressure topographic plots, where functionality
of the upper and lower sphincter and the motility in the
esophagus can be investigated simultaneously and with a
greater spatial solution than with conventional manometry
(Fox et al. 2008;Pandolfinoetal.2008).
1.2 Manometric Findings
The manometric tracings are classified according to
generally accepted criteria:
Fig. 1 Esophageal manometric recordings 15 cm (E1), 10 cm
(E2), and 5 cm (E3) above the oral border of the lower
esophageal sphincter (LES) during continuous drinking (swill)
in a patient with normal LES relaxation, followed by a normal
peristaltic contraction with normal amplitude and duration
1. Normal: Mean LESP 10–30 mm Hg, and normal
swallow-induced relaxation of LES. In the body of
the esophagus peristaltic pressure waves with a
mean amplitude distally 30–110 mm Hg, and
mean duration distally maximal 5.5 s. (Fig. 1).
2. Achalasia: Incomplete relaxation of LES and
aperistalsis and common cavity oscillations in the
esophageal body (Fig. 2).
3. DES: Spontaneous or simultaneous repetitive
broad-based contractions intermingled with normal peristaltic waves (Fig. 3).
4. Nutcracker esophagus: Peristaltic waves with
amplitudes of more than 200 mm Hg.
5. Hypomotility: Low amplitude contractions B
30 mm Hg occurring peristaltically or nonperistaltically, with or without low resting LESP.
6. Non-specific esophageal motility disorder
(NSEMD): Abnormal findings derived of classification according to the definitions above.
1.3 Clinical Interpretation
Abnormal esophageal motility can potentially cause chest
pain or dysphagia, or both. Interpretation of the clinical
manometric result is rather simple and limited to a few
possible pathologic observations, e.g., weak or absent
peristalsis, disordered peristalsis, or impaired LES
relaxation.
Although manometry is sensitive in detecting
esophageal motor disorders, it is often non-specific,
Esophageal Manometry and Gastroesophageal Reflux Monitoring 325
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Fig. 2 a Esophageal manometric recordings 15 cm (E1),
10 cm (E2), and 5 cm (E3) above the oral border of the lower
esophageal sphincter (LES) shows non-peristaltic commoncavity waves in the esophageal body during deglutition in
patient with achalasia. Recording in LES shows incomplete
Fig. 3 The manometric
signature after dry, wet, and
solid swallow. Although
pressure peaks are
simultaneous during dry and
wet swallows, the diagnosis of
diffuse esophageal spasms
(DES) is only possible after
the solid bolus
except when achalasia or DES is a suspected (Kahrilas et al. 1994; Nelleman et al. 2000).
2 Gastroesophageal Reflux
Monitoring
GER monitoring can document normal or abnormal
gastric content in the esophagus. Indications for prolonged monitoring include:
1. Patients with typical symptoms of gastroesophageal
reflux disease (GERD) and normal endoscopy.
2. Patients with atypical symptoms of GERD (i.e., noncardiac chest pain,pulmonarysymptoms, hoarseness).
3. Prior to and subsequent to anti-reflux therapy
(medical or surgical).
relaxation. b Esophageal manometric recordings during swill
show a steady increase in baseline pressure in a patient with
achalasia and incomplete LES relaxation. This method can be
used in patients where gastric intubations are impossible.
Compare to Fig. 1
2.1 Technique
Esophageal pH monitoring: Intraluminal pH monitoring
is used to evaluate acidic gastroesophageal reflux. A
widely accepted technique is a catheter-based pH recording system. The basic equipment requirements include a
portable data logger for data storage, a pH electrode, a
computer, and software for analysis of the pH data.
Data logger’s used in esophageal ambulatory pH
studies are lightweight, battery-powered units that can
be worn bythe patient ona waist beltor shoulder straps.
The data logger also has an event marker that can be
activated by the patient during the study to indicate the
timing of symptoms, meals, and recumbency (sleep).
The patient can also recordthese events on a diarycard.
326 K. Aksglæde et al.
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Fig. 4 Compressed 24 h pH graph and period table. Fraction time of pH below 4 is accentuated
The probes are usually 2–4 mm in diameter,
composed of antimony, ISFET (Ion Sensitive Field
Effect Transistor), or glass. Each probe consists of
single or multiple channels which can be customized
for the individual laboratories.
The pH probe is passed through a nostril into the
stomachtoverifyanacidicpH,andthenpositioned5 cm
above the superior margin of the gastro-esophageal
junction(GEJ), identified by manometryor radiography
(Aksglæde et al. 1999, 2003a, b). This probe positioning
avoidspossibleprobedisplacementintothestomach due
to swallow-induced esophagealshortening, which is not
fully compensated by concomitant electrode oscillation
during eating and talking (Aksglæde et al. 2003a, b).
The length of the study should be at least 16 h,
thus allowing assessment of at least two post-prandial
periods and overnight supine position.
Recent technical advance has been incorporation
of an antimony electrode into a wireless capsule,
which can be placed transorally in the esophagus. The
capsule sends data via radiofrequency telemetry to an
external receiver. Endoscopy has to be performed
prior to capsule placement to avoid severe esophagitis
and strictures, which are among the contraindications
for the use of the wireless capsule. The wireless pH
system routinely records for 48 h.
Esophageal Impedance Measurements. Impedance
measurement is based on measurements of changes in
the electrical impedance. Air yields an increase in
impedance, liquid results in a drop in impedance.
Often a thin probe 2–4 mm in diameter is used to
measure pH 5 cm above the LES, and impedance 3, 5,
7, 9, 15, and 17 cm above the LES. This combined
multichannel impedance and pH monitoring can
evaluate all types of GER (liquid, gas, mixed, acid,
and nonacid), and furthermore, the duration and
proximal extent of a reflux event can be evaluated.
(Hirano et al. 2007; Sifrim et al. 2008).
Esophageal Manometry and Gastroesophageal Reflux Monitoring 327
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2.2 Diet and Drugs While Performing
the Study
References
Discontinuing prokinetic agents, drugs that neutralize
acids, and drugsthat have aninfluence on theLESP 24–
48 h prior to an examination is recommended. Proton
pump inhibitors mustbediscontinued at least 72 h prior
to examination due to the accumulation of the drug in
parietal cell canaliculi and the irreversible nature of
proton pump inhibition. During the examination the
patient can eat a normal diet excluding acid food and
beverage, and physical activity need not be restricted.
2.3 Evaluation of GER Monitoring
Acid GER episodes are defined as periods with pH B
4. To obtain a global assessment, several parameters
are often used: The percentage of time pH B 4 for the
whole investigation time (reflux index), percentage of
time pH B 4 in the supine and upright periods, the
number of reflux episodes, number of episodes lasting
more than 5 min, and the longest reflux episode.
Johnson and DeMeester (1986) devised a scoring
system based on these six parameters to calculate the
degree in which reflux patterns differ between individuals (Fig. 4). However, in order to discriminate
between physiological and pathological GER in
adults, the most useful parameter is the reflux index,
with normal values varying from 3.9 to 7.2 % (Kahrilas and Quigley 1996). We have adopted reflux index
\5 % as the upper normal limit when using the
cathter-based system. Some studies have reported a
value of 5.3 % as the upper value using the wireless
system, which may be a consequence of a better tolerability with less restriction in daily activities.
The amount of impedance liquid reflux episodes are
considered abnormal when they exceed 73 episodes/
24 h. Manual differentiation between liquid reflux
episodes, gas reflux, and swallows are still necessary
and rather time-consuming. (Hirano et al. 2007).
Aksglæde K, Funch-Jensen P, Thommesen P (1999) Radiolog-
ical demonstration of gastroesophageal reflux. Diagnostic
value of barium and bread studies compared with 24 h pH
monitoring. Acta Radiol 40:652–655
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better method for location of the gastro-esophageal junction:
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Aksglæde K, Funch-Jensen P, Thommesen P (2003b) Intrao-
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A video-radiographic study. Acta Radiol 44:131–135
Fox MR, Bredenoord AJ (2008) Oesophageal high-resolution
manometry: moving from research into clinical practice.
Gut 57:405–423
Funch-Jensen P, Aksglæde K, Thommesen P (2000) A new
method for the detection of incomplete lower esophageal
sphincter relaxation in patients with achalasia. Scand J
Gastroenterol 35:349–352
Hirano I, Richter JE (2007) The Practice Parameters Committee
of the American College of Gastroenterology. Am J
Gastroenterol 102:668–685
Johnson LF, DeMeester TR (1986) Development of the 24 h
intraesophageal pH monitoring composite scoring system.
J Clin Gastroenterol 8(1):52–58
Kahrilas PJ, Quigley EMM (1996) Clinical esophageal pH
recording: a technical review for practice guideline development. Gastroenterology 110:1982–1996
Kahrilas PJ, Clouse RE, Hogan WJ (1994) An American
Gastroenterological Association medical position statement
on the clinical use of esophageal manometry. Gastroenterology 107:1865–1884
Keren S, Argaman E, Golan M (1992) Solid swallowing vs.
water swallowing: manometric study of dysphagia. Dig Dis
Sci 37(4):603–608
Nellemann H, Aksglæde K, Funch-Jensen P, Thommesen P
(2000) Bread and barium: diagnostic value in patients with
suspected primary esophageal motility disorders. Acta
Radiol 41:145–150
Pandolfino JE, Gosh SK, Rice J, Clarke JO, Kwiatek MA,
Kahrilas PJ (2008) Classifying esophageal motility by
pressure topography characteristics: a study of 400 patients
and 75 controls. Am J Gastroenterol 108:27–37
Sifrim D, Fornari F (2008) Esophageal impedance-pH moni-
toring. Dig Liver Dis 40:161–166
Impedance Planimetry
https://t.me/med1917
Johannes Lenglinger
Contents
1 Introduction.............................................................. 330
2 Technical Principles of Impedance Planimetry... 330
3 Impedance Planimetry of the Esophagus ............. 330
4 Impedance Planimetry of the Esophagus
in Healthy Volunteers ............................................. 330
5 Impedance Planimetry for Investigation
of Dysphagia............................................................. 331
6 Impedance Planimetry in Patients
with Gastro-Esophageal Reflux Disease................ 334
7 Application of Impedance Planimetry
During Therapeutic Interventions ......................... 335
8 The role of Impedance Planimetry in Clinical
Management of Patients ......................................... 336
9 Summary................................................................... 336
References.......................................................................... 336
J. Lenglinger (&)
Motility Laboratory, Department of Surgery,
Medical University of Vienna, Vienna, Austria
e-mail: johannes.lenglinger@meduniwien.ac.at
Abstract
Impedance planimetry is an imaging technique that
displays the distensibility of hollow viscera. Inside a
bag filled with a conductive solution multiple impedance tracings between pairs of electrodes are converted
to estimate cross sectional areas. With simultaneous
measurement of intrabag pressure distensibility
(smallest cross sectional area vs. intrabag pressure) is
calculated. Impedance planimetry measurements characterize biomechanical properties of the esophagogastric junction,theesophageal bodyand the pharyngoesophageal sphincter. In healthy volunteers distensbiliity of the esophagogastric junction was lowest at the
diaphragmatic hiatus andcross sectional areasof38, 94,
and 264mm2 atdistension volumes of 20, 30and 40ml
were reported. Distension of the esophageal body
resulted in a cylindrical bag configuration up to a
plateau of 400 mm2 in most subjects. In patients with
achalasia distensibility of the esophagogastric junction
was reduced even when sphincter pressure was in the
normal range. In patients with eosinophilic esophagitis
distensibility was decreased at the esophagogastric
junction and in the tubular esophagus. By contrast, in
subjects with gastro-esophageal reflux disease the
diameter of the esophagogastric junction was larger at
any given intrabag pressure than in controls. In clinical
practice impedance planimetry of the esophagus serves
as a diagnostic test for the work-up of dysphagia,
especially ifstructuralor mucosal lesionsare absent and
peristalsis of the esophageal body is preserved. Impedance planimetry can be performed during or immediately after surgical or endoscopic procedures and is
therefore a valuabletoolfor the adhocassessment of the
effects of therapeutic interventions.
O. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnostic Imaging, DOI: 10.1007/174_2012_640,
Ó Springer-Verlag Berlin Heidelberg 2012
329
330 J. Lenglinger
https://t.me/med1917
Main applications of impedance planimetry are the
1 Introduction
Impedance planimetry is animaging technique that isable
to assessthe distensibilityof organsin the alimentary tract.
Tonic and phasic muscular contractions as well as wall
compliance determine the dimensions of hollow viscera
and themovement of contents within them. In areaswith a
narrow lumen, i.e. the esophagus, the antroduodenal
segment and the anorectum, motility can be studied by
manometry. However, the correlation of pressure measurements with symptoms and radiological transit studies
is poor in many disease states because only muscular tone
and contractions can be studied by manometry. Impedance planimetry combinesan estimation ofcross sectional
areas with pressure readings and thus characterizes biomechanical properties of the organ wall. In the clinical
setting this new imaging tool is currently used for the
evaluation of dysphagia and as monitoring instrument
during antireflux surgery and cardiomyotomy.
2 Technical Principles of Impedance
Planimetry
Impedance planimetry is an examination technique that
uses measurements of AC voltage to estimate cross-sectional areas of aliquid conductor contained ina cylindrical
bag. An array of ring electrodes mounted on the catheter
segment inside the bag delineates the measurement area.
The outermost electrodes are connected to a low voltage
AC currentsource.Via infusionports near theends, the bag
is gradually filled with a saline solution. Voltage measurements are made between pairs of electrodes. Since
electrical current, the conductivity of the fluid and the
distance between the electrodes are constants, impedance
(the resistance to AC current flow) is proportional to the
cross-sectional area of the conductor, i.e., the liquid column. Impedance measurements are converted to diameter
estimations and a dynamic image of the bag geometry is
created and displayed on a screen in real time at 10 frames
per second. Simultaneously, a solid-statepressuretransducer monitorsintra-bag pressure.Currently an impedance
planimetry system is commercially available as Endo-
Ò
FLIP
(Endolumenal Functional Lumen Imaging Probe).
A central unit with a display and a motor syringe is connected to a disposable catheter equipped with a bag that
comprises 16impedance tracingsover a measurement area
of 8 cm in length. (Fig. 1).
assessment of esophago-gastric junction and esophageal
body distensibility asthese regions areeasily accessible by
catheter and have a narrow lumen. In practice, an initial
distension is performed in a calibration tube. Thereafter,
the catheter is inserted transnasally or via the instrumentation channel ofthe endoscope and it isadvanced until the
center of the measurement bag is in the region of interest.
By convention, distensibility at rest is assessed with filling
volumes of 10 to 50 ml in 10 ml increments over 30 s,
respectively. The smallestcross-sectionalarea in theregion
of interest and the corresponding distensibility index
(cross-sectional area vs. intrabag pressure) are parameters
used to characterize distensibility (Kwiatek et al. 2010a).
3 Impedance Planimetry
of the Esophagus
The esophagusis a muscular tube of 20–25 cm in length
thattransportsingestafromthepharynxintothestomach.
Sphincter at the proximal and distal ends of the organ
contribute to the regulation of in- and outflow. The highpressure zone at the esophago-gastric junction is crucial
for the protection against reflux of gastric contents into
theesophagus.Esophageal transportfunctionandgastroesophageal reflux activity are determined by organ
geometry, muscular tone and relaxation at the sphincter
regions, peristalsis and wall compliance. At present,
impedance planimetry is the most useful imaging technique to measure biomechanical wall properties. The
application of this technique in the clinical work-up of
esophageal disorders is the subject of this chapter.
4 Impedance Planimetry
of the Esophagus in Healthy
Volunteers
In healthy subjects the high-pressure zone at the
esophago-gastric junction is to the most part located in
and below thediaphragmatic hiatus. Restingpressure is
highest at the hiatus. Conversely, the lumen at this
location assumes an hourglass-shape with volumetric
distension and the hiatus is the least distensible area.
The cross-sectional areas and intrabag pressure
increase with filling volume with a tendency towards a
higher distensibility index at higher volumes. Median
values of the smallest cross-sectional areas were
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