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Diagnosis of oesophageal motility disorders has been well established for many years now, although circadian gastrointestinal motility is still purely understood. So far, high-resolution manometry (HRM) is only available for short-term measurement in clinical practice to evaluate simultaneous pressure conditions throughout the esophagus. Thus, only a very limited period of time can be investigated. There is evidence that disorders in esophageal motility can cause severe discomfort and symptoms even though they only tend to occur spontaneously. When performing short-term-measurements, these often cannot be detected. Therefore, one can assume that long-term analysis of the esophageal function will provide valuable new insights, which will contribute to more effective medicamenteous and operative treatment in esophageal motility disorders. At our gastrointestinal functional diagnostic laboratory, it has been possible to perform high-resolution manometry over the period of 24 hours since June 2014. We used a manometric probe consisting of 36 pressure sensors which are connected to a mobile recording device for ambulatory measurement. This article describes our experiences in clinical use when performing long-term high-resolution manometry and discusses usability and relevance of the results in the context of the underlying esophageal motility disorder., (© Georg Thieme Verlag KG Stuttgart · New York.)

Motility disorders of the esophagus comprise a heterogeneous spectrum of diseases. Primary malformations of the esophagus are now amenable to improved surgical and gastroenterological therapies; however, they often lead to persistent long-term esophageal dysmotility. Achalasia originates from impaired relaxation of the gastroesophageal sphincter apparatus. Systemic diseases may give rise to secondary disorders of esophageal motility. A number of visceral neuromuscular disorders show an esophageal manifestation but aganglionosis rarely extends into the esophagus. The growing group of myopathies includes metabolic and mitochondrial disorders with increasing levels of genetic characterization and incipient emergence of therapeutic strategies. Esophagitis with an infectious etiology causes severe dysmotility particularly in immunocompromised patients. Immunologically mediated inflammatory processes involving the esophagus are increasingly better understood. Finally, rare tumors and tumor-like lesions may impair esophageal motor function.

Dysphagia can be caused by a number of disorders such as benign or malignant obstruction of the esophagus, inflammatory alterations of the mucosa or primary esophageal motility disorders. Endoscopic evaluation is recommended for all patients to exclude malignancy and to establish or confirm a diagnosis. This article provides an overview of the most frequent inflammatory and functional esophageal disorders causing dysphagia. Clinical findings, diagnostic procedures and therapeutic management of primary esophageal motility disorders such as achalasia and diffuse esophageal spasm as well as of GERD and eosinophilic esophagitis are discussed. The diagnosis of achalasia is made by barium swallow with fluoroscopy and by manometry. Therapeutic options for achalasia are pneumatic dilatation of the esophagogastric junction, laparoscopic cardiomyotomy combined with fundoplication and botulinum toxin injection of the lower esophageal sphincter Diffuse esophageal spasm is manometrically characterized by normal peristalsis intermittently interrupted by simultaneous contractions. Potential medical therapies are PPIs for underlying GERD, smooth-muscle relaxants and antidepressant medications. GERD is a multifaceted disease caused by abnormal reflux of gastric contents into the esophagus leading to chronic symptoms or mucosal damage. Therapy includes lifestyle modifications, acid suppressive medications mainly by PPI and laparoscopic fundoplication in selected patients. Eosinophilic esophagitis is a chronic inflammatory disorder of the esophagus diagnosed histologically. The main symptom of eosinophilic esophagitis is dysphagia for solid food with imminent risk of food impaction. Systemic or topical corticosteroids are the therapy of choice.

Background: Oesophageal manometry has become a standard investigation in the management of functional disorders of the oesophagus. However, the importance of the various manometry parameters for the surgical management of patients with gastro-oesophageal reflux disease (GERD) has not yet been studied adequately., Aim: This study examined the importance of manometric findings on surgical treatment results in patients with GERD., Patients and Methods: Between January 1995 and January 2000, 123 consecutively referred patients with GERD symptoms were studied. Ninety-seven of these (52 women and 45 men, mean age 48 years) underwent Nissen fundoplication in conventional or laparoscopic technique. Preoperatively, each patient received stationary oesophageal manometry with a water perfusion catheter, gastroduodenoscopy and 24h-pH-metry of the oesophagus. Independent of manometric results, patients received 360 degrees fundoplicatio with 2 cm cuff ("floppy Nissen")., Results: Eighty-five of the 97 patients (88 %) had an incompetent lower oesophageal sphincter. Hypomotility was diagnosed in 17 (18 %). Amotile achalasia and diffuse oesophageal spasms were seen in two and one patient, respectively, who were not operated on. Follow-up data were available for 92 % of patients (mean follow-up time 1.8 years). Five and 8 patients (1 and 2 of these with hypomotility) postoperatively developed persistent dysphagia and GERD recurrence, respectively (relative risks 1.2 and 1.6). Two patients (one with hypomotility) required surgical revision., Conclusions: Preoperative oesophageal manometry in GERD patients is useful only for determining the position of the upper boundary of the lower oesophageal sphincter and for ruling out specific motility disorders. In patients with oesophageal hypomotility, "floppy Nissen" fundoplicatio can be performed without an excess risk of dysphagia.

Background: Gastrosophageal reflux disease (GERD) of long duration is frequently associated with impaired esophageal body motility. This condition has been considered unsuitable for antireflux surgery., Methods: In order to investigate the outcome of antireflux surgery in the presence of impaired esophageal peristalsis, we studied 67 consecutive GERD patients with poor esophageal body function who underwent laparoscopic partial posterior fundoplication. A standardized questionnaire, upper GI endoscopy, esophageal manometry and 24-hour pH monitoring were performed preoperatively and at a median of 28 months (range, 6-54 months) postoperatively. Esophageal motility was analyzed for contraction amplitudes in the distal two thirds of the esophagus (level 3, 4, and 5), frequency of peristaltic, simultaneous and interrupted waves and total number of defective propagations. In addition, parameters defining the function of the lower esophageal sphincter (LES) were-evaluated., Results: Following antireflux surgery 65 patients (97%) were free of heartburn and regurgitation and had no esophagitis on endoscopy, confirmed by histology. The rate of dysphagia was reduced from 49% preoperatively to 9% postoperatively (p < 0.001). There was significant improvement in esophageal peristalsis after the antireflux procedure. The median DeMeester reflux score was reduced from 33.3 to 1.1 (p < 0.001). Lower esophageal sphincter pressure and intra-abdominal length were normal after surgery., Conclusions: Partial posterior fundoplication provides an effective antireflux barrier in patients with impaired esophageal body motility in the long term. Postoperative dysphagia is avoided by improving esophageal body function.

Background and Objective: It has been noted in previous manometric examinations of the oesophagus in patients with chest pain that abnormal motility was often associated with arterial hypertension. A systematic study of this relationship was therefore undertaken., Patients and Methods: In 40 patients with chest pain (18 women and 22 men, mean age 54.7 [24-70] years) and in 20 healthy volunteers (12 men, 8 women, mean age 50.8 [22-63] years) standardized oesophageal manometry and arterial blood pressure monitoring were performed over 24 hours. Coronary heart disease and gastrointestinal lesions had been excluded by angiography and endoscopy, respectively., Results: 20 patients (group H) had hypertension (median 24-hour blood pressure > 135/85 mmHg), while 20 patients (group N) and the normal controls (group K) were normotensive. Oesophageal manometry data differed significantly between the three groups regarding distal pressure amplitude (in hPa [hectopascals]; group H: 62 hPa*,**, group N 44 hPa* and group K 36 hPa**; [*P < 0.0005]) and the proportion of simultaneous contractions (group H 23%, group N 22%**, group K 10%***; ***P < 0.001). The hypertensive patients had significantly more frequent motility abnormalities than normal controls (13/20 vs 4/20, P < 0.001); while normotensive patients had more frequent episodes of abnormal propulsion in the oesophagus (proportion of propulsive contractions in group H: 53%, in N: 44%, in K: 59%; P < 0.01)., Conclusion: Oesophageal motility differed significantly in patients with chest pain from that in healthy controls. Patients with chest pain and hypertension more frequently had oesophageal hypermotility. This suggests a generalized abnormality of smooth muscle.

Manometry and pH-metry are essential in the examination of functional disturbances of the esophagus. Proven indications for manometry are dysphagia of unknown origin and noncardiac chest pain; in reflux esophagitis manometry is used for measuring pressure of the lower esophageal sphincter and detecting motility disorders of the esophageal body, pH-metry is used as long-term pH-metry to quantify gastroesophageal reflux during day and night; furthermore long-term pH-metry is important in the classification of atypical esophagitis. Recording gastroesophageal reflux and esophageal motility may influence planning of therapy and predict prognosis. Before antireflux surgery manometry and pH-metry are useful in judging the clearance mechanisms of the esophagus. Used critically, manometry and pH-metry can be very helpful as cost-effective diagnostic tools in the long-term therapy of reflux esophagitis.

Esophageal and anorectal motility have not been systematically evaluated in patients with sphincter of Oddi dysfunction (SOD). We have investigated 8 consecutive patients (6 females, 52.5 +/- 9.5 y) with type I-SOD (according to the Milwaukee-classification), 12 patients (9 females, 50.4 +/- 12.3 y) with type III-SOD, and 20 healthy volunteers (15 females, 48.5 +/- 15.2 y) by means of a standardized questionnaire for esophageal and anorectal symptoms, esophageal manometry, colonic transit time evaluation, and anorectal manometry. Symptom-scores did not differ significantly between type-I and type III-SOD-patients, respectively. Furthermore, there were no relevant differences of the symptom-scores of the SOD-patients vs. healthy subjects. However, the lower esophageal sphincter pressure (LESP) was significantly higher in patients with type I-SOD (26.8 +/- 7.4 mmHg) than in both, type III-SOD-patients (20.3 +/- 4.0 mmHg, p < 0.05) and healthy subjects (18.6 +/- 3.5 mmHg, p < 0.001), respectively. Mean colonic transit time did not differ significantly between both groups of patients (type I-SOD, 27.9 +/- 21.4 h, vs. type III-SOD, 28.5 +/- 15.1 h, p < 0.05). The anal sphincter resting pressure (ARP) was significantly higher in patients with type I-SOD (90.8 +/- 15.5 mmHg) than in healthy subjects (74.1 +/- 10.3, p < 0.01), but did not differ significantly from that in patients with type III-SOD (82.1 +/- 11.5 mmHg, p = 0.17). Computer-assisted "beat-to-beat"-evaluation showed an abnormal heart rate variability in 3/8 patients with type I-SOD. These results give evidence for a systemic involvement of the lower esophageal and the anal sphincter in patients with type I-SOD, which does not occur in patients with type III-SOD.

Diagnosis of esophageal motility disorders is difficult due to the large physiologic variability of bolus transport. With the help of a parametric multiple swallow technique (introduced by Tatsch), using "condensed images" of each single swallow action before creating a "mean image" of six swallows, this problem can be solved. For testing this relatively new method, 12 patients underwent 16 pairs of parametric esophageal scintigraphy and esophageal manometry. This collective of patients consisted of 4 with achalasia and secondary hypomobility of the tubular esophagus, 7 with unspecific esophageal dysfunction confirmed by manometry and 1 with clinical dysphagia and normal status in manometry. Fourteen of 15 pathological manometric findings could be confirmed with parametric scintigraphy. Esophageal manometry was false negative in one case and esophageal scintigraphy in another one case. The calculated emptying rates 10 and 12 s after beginning of swallowing are (mean +/- SD) 56 +/- 34% and 60 +/- 34% respectively for solid meal and 54 +/- 25% 57 +/- 22% respectively for liquid meal. Of 60 emptying rates, 48 are in the pathologic range of less than 80%. As expected, no significant difference was found between emptying rates after 10 and 12 s (two-tailed matched pairs t-test. 5% significance level). In conclusion, parametric esophageal multiple swallow scintigraphy has been proven to be a non-invasive and sensitive tool for pre- and posttherapeutic care of patients with esophageal motility disorders. It should be mentioned that esophageal scintigraphy can give additional information in some cases of normal esophageal manometry.

Manometry and pH-metry are essential in the examination of functional disturbances of the esophagus. Before they are used, morphological lesions have to be excluded. Proven indications for functional methods are symptoms which cannot be clarified otherwise. Indications for manometry are: dysphagia of unknown origin, noncardiac chest pain and necessary preoperative studies. Indications for long-term pH-metry are: atypical reflux symptoms, (in particular chronic respiratory disease), noncardiac chest pain, atypical esophagitis and preoperative examination prior to antireflux surgery. Used critically, manometry and pH-metry can be very helpful as cost-effective diagnostic tools.

The results of a cardiologic work-up in patients with retrosternal pain are negative in about 20-30% of cases. Overall one half of these patients exhibit an esophageal dysfunction. In order to diagnose esophageal dysfunction long-term pH-metry, transit scintigraphy and standard manometry are used as well as provocation tests. New diagnostic procedures such as long-term manometry and combined long-term pH-metry and manometry have recently been developed and are increasingly used. Long-term pH-metry is a valid, uncomplicated and sensitive procedure used to diagnose acid gastroesophageal reflux. The differential diagnosis of hypermotility esophageal dysfunction is, however, considerably more difficult. Scintigraphy appears unsuitable. The value of standard manometry is hindered by the short examination time and the rare possibility to correlate pain episodes and motility disorders. It is therefore recommended that a provocation test should be carried out after standard manometry. Preliminary results for long-term manometry are now available. These show that it is not only possible to correlate pain episodes and motility disorders but also to differentiate pathological manometry profile. This applies also to combined pH-metry and manometry reducing patients discomfort to one examination.

Unlabelled: The purpose of this study was to evaluate the role of a "barium-rice" study for diagnosis of dysphagia and oesophageal motility disorders., Material and Methods: 203 patients with oesophageal motility disorders of various aetiologies were examined by both conventional barium study and a "barium-rice" study. During the latter, oesophageal clearance of a defined mixture of barium sulfate and boiled rice was measured., Results: The conventional barium study revealed prolonged transit time in only 15.8% (32 of 203 cases), whereas barium-rice study was pathological in 50.8% (103 to 203 cases). In 71 of 171 patients (41.5%) with a normal barium study, barium-rice passage was prolonged. In 23 patients, radiological results were confirmed by manometric measurements., Conclusion: Oesophageal motility disorders are detected by a barium-rice study with high sensitivity independent of the underlying disease. The barium-rice study offers a simple diagnostic tool revealing quantitative and reliable results. The barium-rice study is a suitable method for screening and follow-up of patients with dysphagia and oesophageal motility disorders.

Esophageal diseases frequently cause symptoms such as heartburn, epigastric pain and dysphagia. This article discusses the indications, techniques and limitations of currently available diagnostic procedures. Investigation of symptoms should proceed in a logical stepwise manner, beginning with endoscopy to exclude esophagitis or neoplasia. Symptoms due to acid reflux can be identified by 24h esophageal pH-metry to document a temporal association between symptoms and episodes of esophageal acidification. Stationary or ambulatory manometric recording of esophageal pressures can be used to diagnose esophageal motor disorders such as achalasia, nutcracker esophagus, diffuse esophageal spasm, or dysfunction of the upper or lower esophageal sphincter. Combined 24 h pH-manometry should be used to test the temporal association between pain, reflux, or abnormal motility in patients with non-cardiac chest pain. Video-fluoroscopy is the most appropriate technique to diagnose swallowing disorders. Pulmonary aspiration of gastro-esophageal reflux can be documented with scintigraphy.

1. In our patients the chronic overindulgence in alcohol led to an increased appearance of a pathological gastrooesophageal reflux. Thereby the group with normal liver findings or steatosis showed a slightly pathological, the group with alcoholic liver cirrhosis a severe pathological reflux behaviour. 2. The manometric findings in form of a decreased resting pressure in the inferior oesophageal sphincter, a slightly increased duration as well as of a decreased speed of the contraction wave were certainly insignificant in functional respect. They could not explain the pathological reflux behaviour. 3. The chronic abuse of alcohol did not lead to erosive changes of the mucous membrane in the distal oesophagus.

In the years 1979-1986, 73 patients with esophageal achalasia, 110 patients with the reflux disease of esophagus and paraesophageal herniae, 17 patients with esophageal diverticles and 33 patients with duodenal ulcer were examined. The patients were examined before the intervention and controlled repeatedly after the operation in the intervals up to one month, after 3-12 months and after 2-7 years. The contribution of manometry is considered to be in giving more precision to the diagnosis and, particularly in esophagocardial achalasia, in determining a suitable operation tactics. In the reflux disease of esophagus it can contribute to the decision between a conservative and surgical therapy. The postoperative control examinations help to make an exact evaluation of the results of operation in a complex with other methods of examination.

Established single-swallow techniques for the assessment of oesophageal motility disorders encompass a high potential of falsely positive/negative findings caused by the considerable variability between single swallows. In this study, therefore, a new form of parametric oesophageal scintigraphy (POeS) is introduced which allows simultaneous assessment of 15-20 consecutive swallows. To assess the value of this combined qualitative/semiquantitative method 166 patients with various oesophageal motility disorders were tested in an intraindividual comparison with a standard oesophageal transit test (OeTT). In contrast to OeTT, POeS yields specific image patterns which permit a differentiation between various forms of peristaltic disorder. By the use of POeS the bolus behaviour during its oesophageal passage is well characterized, the main location of the functional disorder can be identified and a correct classification of the severity can be achieved as well. In contrast to OeTT, diagnosis in POeS is based on a series of consecutive swallows. Misinterpretation due to possible variations between single swallows is often observed in OeTT, providing up to 30% false-positive and 52% false-negative findings which are almost eliminated using POeS.