Manometry

“Manometry is a diagnostic test that measures changes in intraluminal pressure

and the coordination of activity in the muscles of the GI tract.” 1

1 Amy Carpenter Aquino, ed. Gastroenterology Nursing: A Core Curriculum, 4th edition ("n.p."

Society of Gastroenterology Nurses and Associates, Inc. 2008) 319.

Learning Objectives

After attending this presentation, the learner will be able to:

Describe the general principles, equipment and procedures typically employed in manometry studies.

List the types of manometry: Esophageal, stomach and small bowel,

Sphincter of Oddi and anorectal. Their indications and contraindications.

Discuss the manometry patterns of normal subjects and common abnormal studies.

Describe an awareness of Chicago Classification editing and Impedance

Studies.

Three components to the equipment for any manometry:

•Probe with sensors - positioned in the lumen you are testing.

•Transducer - a device that transforms a pressure value into an electrical signal

•Computer or physiography – a system that displays a graphic image for editing and interpretation

Types of Manometry

•Esophageal

•Gastroduodenal small bowel

•Sphincter of Oddi

•Anorectal

Esophageal manometry

Anatomy

Physiology

Primary versus secondary peristalsis

Graphic view of secondary peristalsis

Indications for Esophageal Manometry 2

•Dysphagia

•Non-cardiac chest pain

•Pre-operative evaluation for anti-reflux surgery

•GERD

•Determine location of LES for placement of pH probe

•Evaluate diseases affecting the GI tract such as scleroderma

•Exclude esophageal etiology for suspected anorexia

2 Aquino 319

Contraindications for Esophageal Manometry

•Uncooperative patients

•Recent gastric surgery

• Severe esophageal ulcers

•Known obstruction

•Recent administration of sedatives or narcotics

•BRAVO pH study within 2 weeks

Esophageal Manometry solid state probe

High Resolution 32 sensor Manometry Probe

3 Smith, Paulette, "High Resolution Impedance Manometry" On-site Training Manual, Sandhill

Scientific, Highlands Ranch, CO, LaCrosse, 30 Jan. 2015.

Graph recording of Esophageal Manometry

Normal Values for Esophageal Manometry 4

•Esophageal body amplitude: 30 – 180 mmHg

•Lower esophageal sphincter resting pressure: 10 – 45 mmHg

•Lower Esophageal relaxation pressure: < 8 mmHg.

4 Smith

Achalasia5

5 Smith

Graphic view of Achalasia

Distal Esophageal Spasm (DES)6

6 Smith

Nutcracker Esophagus 7

7 Smith

Nutcracker

Jackhammer

Ineffective Esophageal Motility (IEM) 8

8 Smith

Scleroderma 9

9 Smith

Provocative Testing to reproduce symptoms

•Bernstein Test – Water infused manometry probe with alternating infusions of saline and hydrochloric acid. Test is positive if patient reports feelings of heartburn. Test not used much with 24 hour Ph testing methods now available

•Tensilon (edrophonium, a short acting cholinesterase inhibitor) – With manometry probe in place in esophagus, IV injection of saline placebo alternating with Tensilon. Test is positive if patient reports same type of chest pain.

Gastroduodenal/small bowel manometry

• Symptoms of delayed gastric emptying:

• Severe gastric retention

•Nausea and vomiting

•Weight loss

•Not used very much except in research as other gastric emptying studies with radioisotope tagged foods are more common

Gastroduodenal Small Bowel Manometry

• Stomach – fundus, body, antrum

•Gastric pacemaker in middle of gastric body

•3 peristaltic waves per minute

•16 to 20 feet small intestine. Short, propulsive movement mixes chyme with intestinal secretions toward cecum.

•Probe placed endoscopically - test may last several hours

•Mostly in larger motility centers and for research

Sphincter of Oddi Manometry

10 Anthony, Catherine Parker, and Norma Jane Kolthoff, Textbook of Anatomy and Physiology St.

Louis: CV Mosby, 1971 p. 404.

Sphincter of Oddi Procedure

Indications

•Abdominal pain

•Elevated liver enzymes

•Dilated common bile duct

Contraindications

•Acute pancreatitis

•Barium in GI tract

•Pregnancy

• Inability to tolerate anesthesia

Anorectal Manometry

Solid State anorectal probe

11 Reveille, R. Matthew, and Linda Knight, "Anorectal Manometry: Advanced Interpretation"

Anorectal Interpretation Seminar, Sandhill Scientific, Crowne Plaza Chicago O'Hare, Chicago 20 Oct. 2006.

Air infused disposable probe

Balloon inflated / 4 directional sensors

12 Reveille, R. Matthew, and Linda Knight, "Anorectal Manometry Basic Concepts" Anorectal Interpretation Seminar, Sandhill Scientific, Crowne

Plaza Chicago O'Hare, Chicago, 20 Oct. 2006.

Anorectal Manometry

Indications•Constipation

• Fecal incontinence

•Rectal/Anal pain

•Pre-surgical evaluation

•Rule out Hirshsprung's Disease,

•Chagas’ Disease

Contraindications•Uncooperative patient

•Patient unable to tolerate due to pain with probe inserted

• Infectious diarrhea

Preparation and Patient Instruction

•Procedure takes about 60 minutes (less in infants)

•Prepare with 2 fleets enemas

•No sedation involved

•Pt awake and lying on left side with parts of the test passive and parts interactive

• Study consists of six phases with instructions before each

•Once probe is out, no restrictions or post care needed

Anatomy of rectum and anal sphincter

13 Reveille, Anorectal Manometry: Basic Concepts

Six steps of the testing

•Resting pressure Study

•Squeeze Study

•Squeeze Duration

•RAIR – Rectoanal Inhibitory Reflex

•Push (Strain) Study

•Rectal Compliance Study

Resting pressure pull through

Rectoanal Inhibitory Response

Push (Strain) Maneuver

Normal values 14

•Sphincter length: Male - 3-4 cm Female - 2.5-3 cm

•Normal sphincter resting pressure: 50 - 120 mmHg

•Normal squeeze pressure is < 100 mmHg above resting pressure (Desirable to have at least 100 mmHg to maintain continence.)

•RAIR – At least a 15 % drop in resting pressure. Begins at 10cc, complete at 60 cc

14 Aquino

Normal Sensation Thresholds

• First sensation – 10 cc (15 cc over age 65)

•Urge sensation – 80-100 cc

•Maximum tolerance – we stop filling balloon at 200 cc

15 Reveille

•Chicago Classification of Esophageal Motility Disorders

•Impedance Manometry and 24 pH Impedance testing

Bibliography1. Anthony, Catherine Parker, and Norma Jane Kolthoff. Textbook of Anatomy and Physiology. 8th ed. St. Louis: C.V. Mosby, 1971.

2. Aquino, Amy Carpenter. Gastroenterology Nursing: A Core Curriculum. 4th ed. N.p.: Society of Gastroenterology Nurses and Associates, 2008.

3. Griffin, Vanessa. Gastroenterology Nursing: A Core Curriculum. 3rd ed. N.p.: Society of Gastroenterology Nurses and Associates, 2003.

4. Groer, Maureen E., and Maureen E. Shekleton. Basic Pathophysiology: A Conceptual Approach. St. Louis: C.V. Mosby, 1979.

5. Kahrilas, P.J., et al. “The Chicago Classification of esophageal motility disorders, v3.0”. Neurogastroenterology & Motility 27 (2015): 160-174.

6. O’Connor, Wendy. “Chicago Classifications”. Conference call with shared computer network access. Sandhill Scientific. Highlands Ranch, CO. LaCrosse, WI 17 Mar. 2015.

7. Reveille, R. Matthew, and Linda Knight. “Anorectal Manometry: Advanced Interpretation”. Anorectal Interpretation Seminar, Sandhill Scientific. Chicago: 20 Oct. 2006.

8. Reveille, R. Matthew, and Linda Knight. “Anorectal Manometry: Basic Concepts”. Anorectal Interpretation Seminar, Sandhill Scientific. Chicago: 20 Oct. 2006

9. Schuster, Marvin M., Michael D. Crowell, and Kenneth L. Koch. Schuster Atlas of Gastrointestinal Motility in Health and Disease. 2nd ed. Hamilton, Ont.: BC Decker, 2002.

10. Smith, Paulette. “High Resolution Impedance Manometry”. On-Site Training, Sandhill Scientific, Highlands Ranch, CO. LaCrosse, WI 30 Jan. 2015.

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