How provocative tests in addition to wet swallows during high-resolution manometry can direct clinical management

Abstract

Purpose of reviewProvocative tests have been advocated to address limitations of high-resolution manometry (HRM) with wet swallows. We describe the commonly used provocative manometric manoeuvres [rapid drink challenge (RDC), multiple rapid swallows (MRS), solid swallows and the solid test meal (STM)], compare their diagnostic yield and accuracy to wet swallows, and outline their role in directing clinical management.Recent findingsProvocative testing with RDC and STM identifies a proportion of achalasia cases missed by standard testing, and RDC can play a similar role to radiology in the evaluation of treatment response. In EGJOO, provocative testing with RDC and STM not only increase the diagnostic yield, but can also help differentiate between spurious cases and those representing true outflow obstruction likely to respond to achalasia-type therapies. MRS and STM can help determine the clinical relevance (or otherwise) of ineffective oesophageal motility, and in this setting, MRS may predict the likelihood of postfundoplication dysphagia. RDC and STM can help identify cases of postfundoplication dysphagia more likely to respond to dilatation.SummaryProvocative testing has been shown to increase diagnostic yield of HRM, clarify inconclusive diagnoses, allows corroboration of dysmotility with patient symptoms and helps direct clinical management.

Diagnosis of Ineffective Esophageal Motility According to Chicago Classification Version 4.0: More Stringent Criteria, but Also New Difficulties

“…Consequently, there is some concern in managing such an ambiguous situation.Our group evaluated the use of additional tests to support the diagnosis of IEM such as multiple rapid swallows' or rapid drink challenge performed in both positions. 3 Even in these contexts, we found mixed results related to the 2 positions. Another possible auxiliary test described is the use of solid swallowing, although scientific evidence to support this test is still lacking.…”

“…Another possible auxiliary test described is the use of solid swallowing, although scientific evidence to support this test is still lacking. 3 In these complex situations, we provided an "inconclusive" diagnosis of IEM and recommended a 24-hour pH-impedance testing to assess for the presence of gastroesophageal reflux disease and a further manometric assessment after at least 1 year.We hope CC v5.0 will provide more clarity on this topic and allow us to obtain certainty in the diagnosis of IEM according to the new protocol for performing HRM.…”

“…Another possible auxiliary test described is the use of solid swallowing, although scientific evidence to support this test is still lacking. 3 …”