High Resolution Manometry: Case Presentation

By Marek Polomsky, MD Department of Surgery, University of Rochester School of Medicine and Dentistry Rochester, NY

Manometric evaluation has been a vital component in understanding the physiology of the esophagus, as well as recognizing and comprehending various esophageal disorders. In many instances medical patient management and selection of the ideal surgical procedure can be dependent upon the evaluation of the lower esophageal sphincter (LES) and esophageal body. This functional assessment thus has important implications on the strategy of medical and surgical care provided to the individual patient and subsequent patient outcomes.

Esophageal manometry has been utilized in clinical practice since the 1970's, with Clouse and Staiano's introducing the concept of high resolution manometry in the 1990's.  Only recently has high resolution manometry been incorporated into clinical practice.  And immediately it has demonstrated an advance over conventional manometry.  The 36 channel sensor catheter, with sensors spaced 1 cm apart, provides pressure sensors in such close proximity to each other that, by interpolating between sensors, intraluminal pressure becomes a spatial continuum.  The development of sophisticated algorithms to display this expanded manometric dataset as pressure topography plots has transformed esophageal manometry into an image based paradigm which offers advantages over conventional methods for both research and clinical practice.  As a result, high resolution manometry facilitates assessment of both the esophageal body and lower esophageal sphincter characteristics.  And importantly it has become beneficial for the patient where elimination of the cumbersome pull-through procedure during the study has improved patient comfort and decreased the times to conduct the study.   

Obtaining manometric data from the patient during high resolution manometry starts by explaining to the patient what the study entails.  The catheter is then inserted transnasally into the patient to traverse the entire esophagus with most distal tip in the stomach.  A system for high resolution manometry (Sierra Scientific Instruments; Los Angeles, CA) has been developed that uses a 4.2mm diameter catheter with 36 solid state-state circumferential sensors spaced at 1 cm intervals that span the entire length of the esophagus.  Each of the pressure sensors has 12 radially dispersed vectors, and all 36 channels are averaged together to provide an extended frequency response solid-state manometric system. A resulting topographic (color contour) plot is made that provides a continuous depiction of pressure along the entire recording segment, which enables analysis.  Ten swallows are given in supine position of 5cc liquid material.  After the completion of the 10 swallows the study is completed and analysis is commenced. Obtaining and analyzing the data is straightforward, yet with the interpolating diagnostic power of high resolution manometry even complicated patient cases can be tackled and understood. 

Case Presentation
We present at interesting case of a complex patient whose medical and surgical care was significantly aided by the use of high resolution manometry.  The patient is an 83 year old male who presents to the thoracic and foregut clinic with the chief complaint of dysphagia, or trouble swallowing.  He states that this trouble swallowing has been most severely noticeable the last several months, although upon further questioning he remembers it being present for as long as 5 to 10 years.  He describes a "hang up" sensation in his lower esophagus and chest if he eats too much. If he eats large amounts, he regurgitates bland material.  Otherwise he does well with small portions, and he typically eats 5 meals per day.  The symptom of dysphagia he describes being present with every meal.  As a consequence of all of this he prefers softer foods. He tolerates liquids reasonably well.  The patient does report a 15 pound weight loss over the last several weeks.  He reports occasional heartburn, however he denies having any other foregut or respiratory symptoms.

The patient's past medical history is significant for coronary vascular disease, with a past history of myocardial infarction.  He also has a history of atrial fibrillation, for which he is anticoagulated and has had a pacemaker placement.  In addition the patient reports a history of aortic valve stenosis, hyperlipidemia, degenerative disc disease of the spine, and benign prostatic hypertension.  The patient's medications include lipid lowering agents, aspirin, diuretics, acid-suppressive medications, and oral anticoagulation medications.  The patient is happily married with his wife and he has two sons.  The patient denies having ever smoked.  He occasionally drinks alcohol. On review of systems the patient reports having chest pain episodes described as "chest tightness" attributed to exercised induced angina secondary to his cardiovascular disease.  He occasionally has swelling in his legs and back pain.  

After talking to the patient and obtaining a thorough history, a complete physical exam was performed.  The patient was a healthy appearing elderly man, slightly overweight, in no acute distress.  He was afebrile with normal blood pressure.  His head and neck exam was within normal limits without any lymphadenopathy.  He had marked thoracic kyphosis, with a visible pacemaker was present in his right upper chest. His lungs were clear with a regular heart rate and rhythm.  His abdomen was soft, nondistened, nontender, with normal bowel sounds and no masses palpated.  He did not have any extremity edema.

To further help elucidate the cause of his dysphagia, the patient next underwent an evaluation with various diagnostic modalities.  A barium esophagram was first performed.  (Figure 1)  The study demonstrated a large Type III hiatal hernia with an intrathoracic stomach. In addition there were not any mucosal abnormalities identified, however the esophageal body had weak peristaltic contractions.  The patient next went on to have an upper endoscopy.  This study demonstrated and confirmed a complex Type III mixed sliding and paraesophageal hiatal hernia with intrathoracic stomach and gastric volvulus.  The esophagus was slightly dilated without any significant retained salivary secretions or food.  There was a distinct squamocolumnar junction with no columnar lining or erosions. 

The patient next underwent a high resolution manometry study.  (Figure 2) The study was obtained to better characterize the esophageal body motility and the lower esophageal sphincter in this intricate patient.  Even with such complex anatomy of an intrathoracic stomach the passage of the catheter was facilitated by the visual pressure references evident on the computer acquisition screen immediately as the catheter was being placed into the patient. After adequate placement that allowed full assessment of the LES and esophageal body, the study was performed and completed after the acquisition of 10 wet swallows.  Analyzing the data demonstrated an obvious hiatal hernia on the high resolution manometry with a short total and absent abdominal sphincter length.  The LES resting pressure was normal.  The esophageal body was characterized by 100% simultaneous isobaric pressurizations of low amplitudes that followed the swallows. There was minimal relaxation of the LES.  This study clearly demonstrated impaired esophageal body motility with a manometric picture of achalasia, a significant finding in this patient with an intrathoracic stomach.

Surgical decision making in patients with an intrathoracic stomach is important and often depends on the functional assessment of the esophageal body. The type of operative repair and fundoplication are tailored based on the esophageal body characteristics.  In typical situations with normal motility a routine hernia reduction and repair of the hernia with partial or complete fundoplication is preferred.  However in our patient as a consequence of the discovered manometry findings of impaired motility, we elected to perform a hernia reduction with repair of the diaphragmatic hernia, distal esophageal myotomy, and a partial fundoplication.

The patient tolerated the surgery well and had an uneventful postoperative hospital course.  In his follow-up visits the patient reported resolution of his dysphagia.  In addition he denies any nausea, regurgitation, weight loss, and is able to eat a regular diet.

Conclusion
High resolution manometry shaped the care of our patient.  It is a new and innovative diagnostic modality in the assortment of esophageal function tests that has improved the ability to study, as well as redefine esophageal motility.  With greater patient comfort and more intuitive interpretative analysis, high resolution manometry has become a key component in the functional assessment of esophageal disease. 

Figure 1. Barium esophagram demonstrating a large Type III hiatal hernia with an intrathoracic stomach.

Figure 2. High resolution manometry depicting simultaneous pressurizations of low amplitudes, a defective lower esophageal sphincter with short total length, and a hiatal hernia.

Contact details:
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