Clinical Use of Esophageal Physiologic Testing

Patient Guideline Summary

Publication Date: August 12, 2020

Last Updated: March 3, 2023

Objective

This patient summary means to discuss key recommendations from the American College of Gastroenterology (ACG) for the clinical use of esophageal physiologic testing. It is limited to adults 18 years of age and older and should not be used as a reference for children.

Overview

Esophageal symptoms can occur from different esophageal disorders including gastroesophageal reflux disease (GERD), esophageal mobility problems, and functional problems (problems affecting a function of an organ without structural change).
Esophageal obstructive symptoms include difficulty in swallowing and regurgitation (the effortless return of gastric contents upward toward the mouth. It is often accompanied by acid or bitter taste).
- Regurgitation is different than vomiting which is a more forceful return of stomach contents, usually preceded by nausea.

The purpose of physiologic esophageal testing is to be certain of the diagnosis because symptoms alone can suggest several esophageal and non-esophageal diseases.
No test should be performed without first taking a detailed medical history.
We will use the word “gastric” to describe anything related to the stomach.
This patient summary focuses on the use of these tests.

Esophageal physiologic testing

There are several possible tests your doctor may suggest to reach a conclusive diagnosis.

Your doctor may ask you to fill a questionnaire about these symptoms, but this questionnaire alone is not enough to diagnose specific esophageal conditions.
You may undergo high-resolution manometry (HRM) for evaluation of esophageal motility disorders.
- HRM represents an improvement over conventional manometry (CM). Both use catheters with pressure sensors.
Your doctor may recommend other tests along with the HRM.
- A barium esophagram is an x-ray procedure where barium is swallowed to make the esophagus visible.
  - A barium tablet may be added to the liquid barium during the evaluation.
Your doctor may recommend ambulatory reflux monitoring (24-hour pH reflux monitoring to measure the amount of reflux in your esophagus during a 24-hour period) to supplement patient-reported symptoms on GERD questionnaires.
- Your doctor may recommend the use of ambulatory reflux monitoring rather than just your response to proton pump inhibitor (PPI) therapy.
- If your reflux symptoms do not respond to a PPI, your doctor may recommend the use of ambulatory reflux monitoring rather than upper endoscopy (a procedure when the healthcare provider inserts an instrument with a camera at the end to look inside your body) alone if endoscopy does not provide a conclusive diagnosis.
- If you have typical reflux symptoms and unproven GERD, your doctor may recommend the use of ambulatory reflux monitoring performed off antisecretory therapy (drugs used to decrease the acid secretion) rather than ambulatory reflux monitoring while taking antisecretory therapy.
- If your symptoms are infrequent or vary from day-to-day, your doctor may recommend prolonged wireless pH monitoring rather than 24-hour catheter-based monitoring.
- If you have typical esophageal reflux symptoms and previous proven GERD, your doctor may recommend the use of ambulatory pH impedance monitoring on PPI therapy rather than endoscopic evaluation or pH monitoring alone to diagnose persisting GERD.
- If you are being evaluated for antireflux surgery (ARS), abnormal acid exposure time (AET) may be considered as a predictor of treatment outcome. Reflux symptom association (RSA) and mean nocturnal (night) baseline impedance (BI) provide additional value.
  - BI measures esophageal mucosal integrity and esophageal acid burden. BI is decreased in GERD.
If you have esophageal symptoms after ARS, your doctor may recommend that the esophagogastric junction (EGJ) and gastric cardia (the part of the stomach that is closest to the esophagus) anatomy be evaluated endoscopically and/or by x-ray to assess mechanical abnormalities.
Ambulatory reflux monitoring performed off acid suppression is recommended rather than laryngoscopy for a diagnosis of extraesophageal reflux.
Up-front ambulatory reflux monitoring off acid suppression is suggested over an empiric (observational) trial of PPI therapy for extraesophageal reflux symptoms if there are no concurrent typical reflux symptoms.
If you have esophageal symptoms suspicious for rumination syndrome (an eating disorder in which undigested food comes back up from the stomach into the mouth), high resolution impedance manometry (HRIM) with postprandial (after eating) monitoring may be used to confirm the diagnosis of rumination if clinically necessary.
If you have excessive belching (burping), pH impedance monitoring can be used to confirm the diagnosis of supragastric belching.

Abbreviations

ACG: American College Of Gastroenterology
AET: Acid Exposure Time
ARS: Antireflux Surgery
BI: Baseline Impedance
CM: Conventional Manometry
EGJ: Esophagogastric Junction
GERD: Gastro-esophageal Reflux Disease
HRIM: High Resolution Impedance Manometry
HRM: High-resolution Manometry
PPI: Proton Pump Inhibitor
RSA: Reflux Symptom Association

Source Citation

Gyawali, C. Prakash MD, MRCP, FACG; Carlson, Dustin A. MD; Chen, Joan W. MD; Patel, Amit MD; Wong, Robert J. MD, MS, FACG (GRADE Methodologist); Yadlapati, Rena H. MD, MSHS ACG Clinical Guidelines: Clinical Use of Esophageal Physiologic Testing, The American Journal of Gastroenterology: September 2020 - Volume 115 - Issue 9 - p 1412-1428 doi: 10.14309/ajg.0000000000000734

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.