Joseph R. Triggs, MD, PhD
John E. Pandolfino, MD, MSCI
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High-resolution esophageal manometry (HREM) and subsequent interpretation using the Chicago Classification (CC) is the gold standard for the diagnosis of esophageal motility disorders.1 The procedure is performed by placing a catheter with a dense series of pressure sensors transnasally with the distal tip ending in the patient’s stomach. Test swallows are then performed and recorded assessing contractile timing and intraluminal pressures. HREM studies are displayed as pressure topography plots or Clouse plots, named after the individual who developed them.2,3 These plots place time on the x-axis, anatomic location on the y-axis, and pressure depicted as color, with warmer colors representing higher amplitudes. HREM replaced traditional line tracing manometry and has led to increased ease of use, uniformity, standardization of objective measures used in the diagnosis of motility disorders, improved interrater agreement, and improved diagnostic yield.4,5,6,7 Despite these advances, HREM is a diagnostic tool that requires special expertise and training to reliably perform high quality studies.8,9,10 Healthcare professionals reading these studies must be able to assess for technical adequacy, which includes ensuring proper placement, recognizing common artifacts and equipment failure, in addition to being able to accurately report the measurements used in the CC to allow for an accurate diagnosis.
Structural abnormalities should be ruled out prior to HREM with upper gastrointestinal endoscopy, esophagram, or other form of structural evaluation of the esophagus.
1. Nonobstructive dysphagia
2. Noncardiac chest pain, regurgitation, rumination, or belching
3. To aid in positioning for pH and pH-impedance testing
4. Prior to antireflux surgery for assessment of swallowing function
1. Esophageal obstruction from an infiltrating process or high-grade constriction
2. Altered nasal passage anatomy preventing catheter insertion
3. High-grade oropharyngeal dysphagia
4. Significant coagulopathy
PREPARATION FOR STUDY
1. HREM catheters are made by several manufacturers and manufacturer instructions should be followed for catheter calibration and recording device setup prior to patient arrival.
2. Informed consent should be obtained and documented.11
3. Patients should have nothing to eat or drink for at least 6 hours before the HREM study to prevent aspiration.
a. For patients with achalasia and esophageal retention, you may want to consider a clear liquid diet for 48 hours prior to the procedure.
4. Patients should be assessed for prior foregut surgery as this can alter interpretation during analysis.
5. The patient medication list should be reviewed specifically for opioids, calcium channel blockers, antispasmodics, nitroglycerin, and muscle relaxants as these can alter study results.
1. HREM catheter (Fig. 52.1)
2. Computer workstation for data acquisition and storage
1. Stretcher or exam table
3. Towel or disposable underpads
4. Syringes with water (or saline for HREM with impedance)
5. Cup with a drinking straw
6. Emesis basin
7. Lubrication jelly
8. 2% viscous lidocaine jelly for topical anesthesia
9. Paper tape for securing the catheter in place
10. Gloves and protective eye wear
11. If provocative or postprandial testing will be performed, the appropriate viscous, solid, or meal items should also be on hand
1. Apply lidocaine 2% jelly to the inside of the nostril you will be using for catheter placement.
2. Tape a disposable underpad to the outside of the patient’s clothing and have the emesis basin on hand.
3. Lubricate the catheter with jelly and place the catheter transnasally into the esophagus, through the esophagogastric junction (EGJ) and into the stomach.
a. Instruct the patient to take small sips of water through a straw as the catheter is entering the nasopharynx.
4. Verify correct placement.
a. Ideally there should be one sensor above the upper esophageal sphincter and 4 to 5 sensors in the stomach. If this is not possible due to the patient’s esophageal length, prioritize having 4 to 5 sensors in the stomach (Fig. 52.2).
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