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

Abstract

Summary Background Standard high‐resolution manometry (HRM) protocols are based on 10 single water swallows acquired in the supine position. Aims To assess the impact of position, rapid drink challenge and solid test meal on the diagnosis of oesophageal motility disorders. Methods Seventy‐two healthy volunteers (20‐76 years) and 366 consecutive patients (18‐90 years) completed HRM with 10 single water swallows in the supine and upright positions. Rapid drink challenge was performed twice, before and after the solid test meal. Diagnosis based on single water swallows in the supine position (Chicago Classification v3.0) was compared with results in the upright position and with provocative tests. Results Overall, diagnostic agreement in the supine and upright positions was present in 296/438 (67.6%) subjects. This increased to 90.0% when ineffective oesophageal motility was considered with normal motility. Integrated relaxation pressure was 4 mm Hg higher in the supine position. There was a higher prevalence of inconsistent, likely false positive, diagnoses of outlet obstruction in the supine compared to the upright position (16/20 vs 1/4 patients, P = 0.0007). Similarly, the difference in concordance for the diagnosis of oesophago‐gastric junction obstruction or achalasia between single water swallows in the supine and upright positions with solid test meal was significant (12/29 (41.4%) vs 12/14 (85.7%), P = 0.0087). Conclusion Diagnostic agreement for oesophageal motility disorders based on single water swallows in the upright and supine positions was moderate, with frequent discordant findings for ineffective motility and outlet obstruction. HRM studies can be performed in either position, using appropriate reference values. Rapid drink challenge or solid test meal can resolve diagnostic discrepancies.

High‐resolution manometry in the upright position could improve the manometric evaluation of morbidly obese patients with esophagogastric junction outflow obstruction

“…In 438 patients who underwent HRM in the supine and upright positions, an agreement was found in only 67.6% of the subjects. 15 The misdiagnosis problem might be more important in morbidly obese individuals since, in the present study of obese patients, all the patients who were diagnosed with EGJOO using supine HRM did not have radiographic evidence of EGJOO. We tried to find new metrics that could identify patients without clinically significant EJGOO in morbidly obese patients.…”

“…Those findings are in agreement with two recent studies that showed a higher prevalence of EGJOO in the supine position than in the upright position. 10,15 Future studies could examine the inclusion of solid swallows as it appears to increase the specificity for clinically relevant EGJOO. 21 In conclusion, HRM studies in patients with morbid obesity should include the upright position to minimize misdiagnoses attributable to anatomical factors and artifacts.…”

Effect of Body Position on High-resolution Esophageal Manometry Variables and Final Manometric Diagnosis

“…Some authors referred that the exam was started in the supine position and the subsequent series of swallows was performed in the sitting/upright position; 12,14,15,18,19,24 other referred the opposite. 16,20,22,23 both to the upright or supine position in the studies by Zhang et al 17,21 and Misselwitz et al 26 Only 5 studies 14,16,17,19,24 reported the inclination assumed by the patient during the exam: between 0° and 20° for the supine position and between 75° and 90° for the upright/sitting position. Every study included at least 5 water bolus swallows per set for each position.…”

“…One thousand seven hundred fourteen patients were included, [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] of whom 1284 were symptomatic and 430 asymptomatic individuals. The sequence of the position assumed during HRM was described in almost all studies.…”

Editorial: upright manometry—a lot more to swallow

“…In the important study by Misselwitz et al , the authors challenge our standard method of manometry by performing additional studies in the upright position in 366 patients and normal volunteers. The results are intriguing, describing differences in basal LOS pressure, IRP, and distal contractile amplitude.…”