Informed Management of Benign Oesophageal Disorders Utilising Oesophageal Physiology Testing

Oesophagealphysiology testing, encompassing Oesophageal Manometry and pH testing, has revolutionised the diagnosis of gastroesophageal conditions.

It can be considered an adjunct to a good history, radiological examination (contrast swallow or CT scan) and endoscopy. Non cardiac chest pain, reflux and difficulty swallowing are among the indications.

Patients with oesophageal symptoms are often referred for endoscopy to exclude mucosal or structural pathology. If endoscopy is normal and/or patients fail to respond to Proton Pump Inhibitors (PPIs), oesophageal manometry and ambulatory pH testing can be considered.

It is important also that some form of imaging (contrast swallow or CT scan) be done in preparation for physiology studies. Contrast swallow fluoroscopy gives us some idea of oesophageal function and hiatal anatomy whilst CT scan with oral contrast gives us a great understanding of anatomy only. It is important to have this information as there is a complex interplay between anatomy and physiology, specifically the relationship of the oesophagus to the diaphragm. If there is a massive hiatus hernia i.e., most of the stomach is in the chest then physiological testing is not able to be performed. Patients with a massive hiatus hernia require referral to a surgeon for hiatal hernia repair.

High resolution manometry involves a fine nasogastric tube being placed, and swallowing tests performed.

The manometry catheter has sensors every 2cm along the length of the oesoph- agus. Spatiotemporal and topographical representation of the pressure data provides a visual representation of oesophageal pressure from pharynx to stomach.

Oesophageal Manometry can aid in evaluating oesophageal motility, identifying any abnormalities that may contribute to reflux, and diagnosing motility disorders such as achalasia.3

For 24-hour ambulatory pH testing, a pH sensing catheter is placed 5cm above the manometrically defined lower oesophageal sphincter. For best results patients should be off all their acid suppressing medication for two weeks. Patients are asked to perform all their usual activities as much as is possible whilst the probe is in place. They record meals, supine moments, and specific symptoms. The probe is removed and the data is analysed. It can help to answer questions such as:

1. Is what the patient describes as “reflux” really gastro-oesophageal reflux?

2. Is the refluxate acid in nature?

3. What is the likelihood of the patient benefiting from anti-acid medication or from anti-reflux surgery?

Oesophageal physiology testing offers a valuable tool for healthcare professionals to determine the appropriate treatment in terms of medications and surgery. By assessing oesophageal pH levels and correlating them with symptoms, clinicians can establish the presence and severity of acid reflux, aiding in maintaining PPI stewardship. A definitive diagno- sis of reflux aids in selecting patients for surgical treatment (fundoplication) for reflux.

Oesophageal physiology testing, encompassing Oesophageal Manometry and pH testing, has improved the diagnostic landscape for various gastroesophageal conditions. Oesophageal physiology testing has an important role in assessing the function of the oesophagus and stomach to guide clinical practice.

DrAnna Isaacs and Dr Candice Silverman, Upper GI, Hernia and Metabolic Surgeons, are pleased to announce that they are commencing oesophageal manometry testing and 24-hour pH monitoring at John Flynn Private Hospital from 30 June 2023.

References

1. Lata T, Trautman J, Townend P, Wilson RB. Current management of gastro-oesophageal reflux disease—treatment costs, safety profile, and effectiveness: a narrative review. Gastroenterology Report. 2023;11 doi:10.1093/gastro/goad008.

2. Heinrich H, Sweis R. The role of oesophageal physiological testing in the assessment of noncardiac chest pain. Therapeutic Advances in Chronic Disease. 2018;9(12):257-267. doi:10.1177/2040622318791392.

3. Sweis R, Fox M. High-Resolution Manometry—Observations After 15 Years of Personal Use—Has Advancement Reached a Plateau? Current gastroenterology reports. 2020;22(10):49-49. doi:10.1007/s11894-020-00787-x.