Diagnosis of Esophageal Motility Disorders: Esophageal Pressure Topography vs. Conventional Line Tracing

Abstract

Background Enhanced characterization of esophageal peristaltic and sphincter function provided by esophageal pressure topography (EPT) offers a potential diagnostic advantage over conventional line tracings (CLT). However, high-resolution manometry (HRM) and EPT require increased equipment costs over conventional systems and evidence demonstrating a significant diagnostic advantage of EPT over CLT is limited. Our aim was to investigate whether the inter-rater agreement and/or accuracy of esophageal motility diagnosis differed between EPT and CLT. Methods Forty previously-completed patient HRM studies were selected for analysis using a customized software program developed to perform blinded independent interpretation in either EPT or CLT (six pressure sensors) format. Six experienced gastroenterologists with a clinical focus in esophageal disease (attendings) and six gastroenterology trainees with minimal manometry experience (fellows) from three academic centers interpreted each of the 40 studies using both EPT and CLT formats. Rater diagnoses were assessed for inter-rater agreement and diagnostic accuracy, both for exact diagnosis and for correct identification of a major esophageal motility disorder. Results The total group agreement was moderate (κ = 0.57; 95% CI 0.56–0.59) for EPT and fair (κ = 0.32; 0.30–0.33) for CLT. Inter-rater agreement between attendings was good (κ = 0.68; 0.65–0.71) for EPT and moderate (κ = 0.46; 0.43–0.50) for CLT. Inter-rater agreement between fellows was moderate (κ = 0.48; 0.45–0.50) for EPT and poor to fair (κ = 0.20; 0.17–0.24) for CLT. Among all raters, the odds of an incorrect exact esophageal motility diagnosis were 3.3 times higher with CLT assessment than with EPT (OR 3.3; 95% CI 2.4–4.5; p<0.0001) and the odds of incorrect identification of a major motility disorder were 3.4 times higher with CLT than EPT (OR 3.4; 2.4–5.0; p<0.0001). Conclusions Superior inter-rater agreement and diagnostic accuracy of esophageal motility diagnoses was demonstrated with analysis using EPT over CLT among our selected raters. Based on these findings, EPT may be the preferred assessment modality of esophageal motility.

Factors Determining the Inter-observer Variability and Diagnostic Accuracy of High-resolution Manometry for Esophageal Motility Disorders

“…We also suggested several explanations for the results that were not in accordance with those of previous studies reporting the advantages of HRM over conventional manometry in diagnostic accuracy. 9,17 First, according to the Chicago classification version 3.0, the number of disease entities with the HRPT format was greater than that in the CLT format (9 vs 6) in the present study. Second, providing the manometry data as captured images from 10 significant swallows with calculated essential metrics, including IRP, DCI, DL, and CFV for the HRPT format and baseline and residual LES pressures, onset velocity and distal contractile amplitude for the CLT format may have facilitated the interpretation of the manometry data, especially in the CLT format.…”

“…Interestingly, the level of agreement was lower in Type I, II, and III achalasia (k value were 0.4, 0.53, and 0.39, respectively) than in cases reported in existing studies. [9][10][11] k values slightly increased among staff members; however, the level of agreement remained moderate with Type I and Type III achalasia (k values were 0.42 and 0.51, respectively). The unique method of the present study might explain those results.…”

“…[2][3][4]22,23 Nevertheless, few existing studies are available that have analyzed the reliability and diagnostic accuracy for distinguishing major esophageal motility disorders from minor motility disorders or a normal state or differential diagnosis among major disorders. 9 Our study is meaningful because we analyzed the exact accuracy and diagnostic accuracy for distinguishing major esophageal motility disorders and disease-or interpreterassociated factors influencing the diagnostic accuracy of the HRM. A recent study by Carlson et al 9 reported that the odds ratio of an incorrect diagnosis of a major motility disorder among all raters was 3.4 times greater with the CLT format than with the HRPT format and that the odds ratio of an incorrect diagnosis was similar according to the interpreter's experience.…”

Practical aspects of high resolution esophageal manometry

“…High resolution esophageal manometry (HRM) has led to advances in the diagnosis and treatment of esophageal motor disorders (1,2). Its incorporation was led by the International High Resolution Manometry Working Group, and provided an opportunity for updating and harmonizing concepts and criteria.…”

High Resolution Manometry - A Mandatory Examination in the Pre and Postoperative Assessment of Patients with Achalasia

“…The technique has gradually replaced conventional manometry, having over the following improvements: increased number of pressure sensors with shorter spacing between (1 cm) allowing a complete depiction of esophageal motor function from upper esophageal sphincter (UES) to lower esophageal sphincter (LES); the visual display simplifies the correct positioning of the catheter (3); significantly shorter procedure time, faster learning curve, more objective interpretation with better interobserver and intraobserver agreement (4)(5)(6)(7) For a correct measurement, a baseline gastric pressure must be recorded. In order to do this, EGJ must be passed and the distal tip of the catheter positioned in the gastric cavity before starting the study.…”