The added value of symptom analysis during a rapid drink challenge in high‐resolution esophageal manometry

Abstract

Over the past 20 years, high-resolution manometry (HRM) has become the gold standard for the diagnosis of esophageal motility disorders. The current HRM-based Chicago classification v3.0 (CC 3.0) 1 makes a distinction between major (achalasia, EGJ outflow obstruction, esophageal spasms, Jackhammer esophagus, and absent contractility) and minor motility disorders (ineffective esophageal motility) of uncertain clinical signification since they can be observed in a significant proportion of healthy subjects and are not clearly correlated with symptoms. 2-6 Consequently, a significant proportion of patients with esophageal symptoms have a normal HRM or an inconclusive diagnosis, therefore without definite explanation for their symptoms nor proposition for management. 7,8 This

Chicago classification version 4.0© technical review: Update on standard high‐resolution manometry protocol for the assessment of esophageal motility

“…Additionally, the occurrence of typical symptoms during RDC in patients referred for investigation of dysphagia or other esophageal symptoms confirms the clinical relevance of any motility disorder identified during testing 29 . Clinical studies have shown that RDC can help to establish a conclusive diagnosis in patients with borderline HRM findings during single water swallows 26‐31 . Furthermore, up to 17% of patients with esophageal symptoms but normal wet swallows have abnormal RDC findings that require further investigation by addition of solid swallows to the HRM protocol and /or other diagnostic tests 31 …”

“…Characteristic findings during RDC include a normal (“hypopressive”) pattern shared by healthy subjects and patients with IEM, that discriminates patients with non‐obstructive hypercontractile motility or achalasia (sensitivity 80% and specificity 93%), (ii) impaired deglutitive inhibition (“brief hyperpressive” pattern) in patients with non‐obstructive hypercontractile disorders (eg, distal spasm, hypercontractile esophagus), and (iii) impaired EGJ function (“prolonged hyperpressive” pattern) with increased RDC‐IRP that discriminates achalasia and EGJOO from other patients groups (sensitivity 70% and specificity 85%) 28 . Additionally, the occurrence of typical symptoms during RDC in patients referred for investigation of dysphagia or other esophageal symptoms confirms the clinical relevance of any motility disorder identified during testing 29 . Clinical studies have shown that RDC can help to establish a conclusive diagnosis in patients with borderline HRM findings during single water swallows 26‐31 .…”

“…Data acquisition in two positions and inclusion of provocative tests can prolong data acquisition and variation in findings between tests can complicate the interpretation of HRM findings. The CCv4.0 working group recognizes that increased time required for data acquisition and analysis could be a barrier to implementation; however, the full protocol can be completed within 15 minutes and the inclusion of this information increases diagnostic sensitivity and specificity for clinically relevant diagnosis of esophageal motility disorders 24‐36 . “Inconclusive” findings on wet swallows can often be confirmed by these tests and, conversely, discordant findings in the secondary position and/or with provocation should prompt reconsideration of the diagnosis.…”

Chicago Classification update (V4.0): Technical review on diagnostic criteria for ineffective esophageal motility and absent contractility

“…Administration of a standardized meal during HRM can also demonstrate latent obstruction and augmentation of esophageal body contraction, although the test is limited because it is cumbersome, time‐consuming, and the meal administered may not be similar across motility centers. Symptom analysis during provocative tests (both RDC and STM) may have adjunctive value in the evaluation of symptomatic patients, but recording and grading of symptoms have not been standardized to date 15,28 …”

Diagnostic yield of adding solid food swallows during high‐resolution manometry in esophageal motility disorders

“…ously,16 but sometimes the test is difficult to interpret due to various symptoms (cough, nausea) occurring in up to 10% of patients with normal or minor motility disorders 25. Further studies are required to determine whether SFS can be useful to confirm an EGJ obstruction (or identify other major esophageal motility disorders) in patients with normal or minor motility with SWS but pressurization during RDC.…”