Esophageal provocation tests: Are they useful to improve diagnostic yield of high resolution manometry?

Abstract

High resolution manometry (HRM) is the gold standard to diagnose esophageal motility disorders but has some limitations. The inclusion of provocative tests might enhance the diagnostic yield of HRM. These tests are easy to perform and to add to the regular manometry protocol. Multiple rapid swallows (MRS; 5 2-mL swallows) is useful to assess the contractile reserve and deglutitive inhibition. The optimal number of MRS to perform might be 3 as suggested by Mauro et al. in this issue of Neurogastroenterology & Motility. The absence of contractile reserve might be associated with gastro-esophageal reflux disease and with an increased risk of post fundoplication dysphagia. Single viscous and solid swallows might enhance the detection of esophageal motility disorders but are not significantly associated with symptom occurrence. Test meal has the advantage to represent a real-life scenario and is promising to depict significant motility findings responsible for esophageal symptoms. Post-prandial recording might also be of interest to diagnose rumination and belching disorders. The best indication of rapid drink challenge test (free drinking of 200 mL) is currently the diagnosis of esophago-gastric junction obstruction. Finally, abdominal compression might be an option to evaluate response of esophageal peristalsis in a context of outflow resistance as proposed by Brink et al. in this issue. These provocative maneuvers appear to provide a complementary role in the evaluation of esophageal motility but require prospective studies to determine the validity of the findings and whether they will lead to changes in clinical practice.

Prospective serial diagnostic study: the effects of position and provocative tests on the diagnosis of oesophageal motility disorders by high‐resolution manometry

“…Normative values for single water swallows in the upright position and for solid swallows using HRM have been published and surveys indicate that many centres have adopted these techniques; however, it is not known how often there is diagnostic disagreement between measurements acquired in the upright and the established supine positions …”

“…15,16 Normative values for single water swallows in the upright position and for solid swallows using HRM have been published [16][17][18][19] and surveys indicate that many centres have adopted these techniques 20 ; however, it is not known how often there is diagnostic disagreement between measurements acquired in the upright and the established supine positions. 21 In this prospective study, we tested the null hypothesis that position would have no effect on diagnosis of major motility disorders. A serial diagnostic design was applied with HRM performed with 10 single water swallows in the supine and upright positions in healthy subjects and a large cohort of consecutive patients referred for investigation of oesophageal symptoms.…”

The differences in the esophageal motility between liquid and solid bolus swallows: A multicenter high‐resolution manometry study in Chinese asymptomatic volunteers

“…Adding solid bolus swallow in the procedure of esophageal manometry, either single solid bolus swallow or solid test meal, improved the diagnostic ability of esophageal motility disorders and the assessment of the symptomatic dysmotility . Hence, solid bolus swallow was accepted as one of the provocative tests during esophageal manometry …”

“…[1][2][3][4][5] Hence, solid bolus swallow was accepted as one of the provocative tests during esophageal manometry. 6 High-resolution esophageal manometry (HREM) is more accurate compared with conventional manometry for the assessment of esophageal motility. 7,8 Using HREM, we had approved the motility of esophagogastric junction (EGJ) was different between solid and liquid bolus swallows.…”

Which Provocation Test Will Be Added to Routine High-resolution Manometry Protocol in Unexplained Dysphagia?

“…Those maneuvers allows stress or load to augment abnormal esophageal response during esophageal peristalsis or transit through EGJ. 3 Multiple rapid swallows (MRS), rapid drink challenge test (RDC), viscous or solid swallows, different test meals, or abdominal compression are used to provoke esophageal responses. [3][4][5][6] Some tests are usually intended to measure contractile reserve, other tests are specially used to detect EGJ obstruction.…”