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 Table of Contents  
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 135-138

Ancillary techniques and maneuvers in high resolution esophageal manometry

1 Department of Gastroenterology, Arihant Hospital and Research Centre, Indore, Madhya Pradesh, India
2 Department of Gastroenterology, Gleneagles Global Health City, Porur, Chennai, Tamil Nadu, India
3 Department of Hepatology, Sri Ramachandra Medical College, Porur; Consultant Gastroenterologist, Gleneagles Global Health City, Chennai, Tamil Nadu, India

Date of Submission12-Apr-2021
Date of Decision19-Aug-2021
Date of Acceptance20-Aug-2021
Date of Web Publication24-Sep-2021

Correspondence Address:
Mayank Jain
297, Indrapuri, Near Bhanwarkuan, Indore - 452 001, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ghep.ghep_15_21

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High-resolution esophageal manometry (HREM) is a technique to determine the function of esophageal musculature and integrity of esophagogastric junction. Conventionally, the HREM study is done in the supine position using ten swallows of 5 ml water each. Apart from this mandatory testing, ancillary testing and maneuvers are undertaken to elicit detailed physiological information. These include multiple rapid swallows, rapid drink tests, testing in the upright position with solid swallows, and pharmacological testing. The present review highlights these techniques and their clinical utility.

Keywords: High-resolution esophageal manometry, multiple rapid swallows, pharmacological testing, postprandial high-resolution manometry, rapid drink challenge, standardized test meal

How to cite this article:
Jain M, Srinivas M, Jayanthi V. Ancillary techniques and maneuvers in high resolution esophageal manometry. Gastroenterol Hepatol Endosc Pract 2021;1:135-8

How to cite this URL:
Jain M, Srinivas M, Jayanthi V. Ancillary techniques and maneuvers in high resolution esophageal manometry. Gastroenterol Hepatol Endosc Pract [serial online] 2021 [cited 2022 Sep 30];1:135-8. Available from: http://www.ghepjournal.com/text.asp?2021/1/4/135/326626

  Introduction Top

High-resolution esophageal manometry (HREM) is a technique to determine the function of esophageal musculature and integrity of esophagogastric junction (EGJ). Most centers in India use a water perfusion system. Such a system consists of several capillary tubes connected to a multi-lumen perfusion catheter and external transducers. Conventionally, the HREM study is done in the supine position. The catheter is passed transnasally and secured at the nostril. The parameters recorded in a study include basal lower esophageal sphincter (LES) pressures, EGJ morphology, and peristaltic pattern with ten swallows of 5 ml water each.

Apart from these mandatory steps, certain ancillary testing and maneuvers are utilized in HREM testing to elicit further detailed physiological information. The present review highlights some of the commonly used ancillary testing techniques with water perfused systems and discusses their clinical utility.

  Physiological Testing using Multiple Rapid Swallows Top

Deglutitive inhibition and augmentation of contraction after repetitive swallowing are normal physiologic phenomena in the esophagus. Repetitive swallowing of small boluses during normal eating and drinking causes inhibition of esophageal body peristalsis and LES tone.[1] Each successive swallow continues to inhibit the progression of the previous swallow, until the last swallow of the sequence, which is followed by an augmented contraction wave. The ability of the esophageal smooth muscle to augment contraction vigor is an important mechanism for clearing the retained esophageal content and improving bolus transit.[2]

Multiple rapid swallows (MRS) are the most commonly used physiologic maneuver during HREM. It helps to evaluate the integrity of esophageal neural innervation and the ability of the esophageal smooth muscle to contract. If the esophageal inhibitory innervation is intact, there is inhibition of smooth muscle contraction and profound LES relaxation during swallows. On the other hand, an intact excitatory neural system potentiates the vigor of contraction after the final swallow of the sequence which is usually more forceful than the contraction seen with single 5 ml swallows. This is termed peristaltic or contraction reserve.

For each MRS tracing, five rapid swallows with 2 ml water are administered within 10 s [Figure 1]. MRS interpretation involves two distinct phases.
Figure 1: Patterns of multiple rapid swallows. (a) Multiple rapid swallow sequence - Complete inhibition with normal contraction, (b) multiple rapid swallow sequence - Incomplete inhibition with normal contraction

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Inhibition phase (multiple rapid swallows-induced esophageal body inhibition)

This is considered incomplete if a contraction measuring >3 cm is identified using the 30-mmHg isobaric contour tool, and complete if no contraction or a small diminutive contraction fragment of ≤3 cm is seen.

Contraction phase (for assessment of rebound contraction)

Distal contractile integral (DCI) is a measure of the force of peristaltic contraction in the smooth muscle segment of the esophagus. It is denoted as amplitude X duration X length of distal esophageal contraction that exceeds 20 mmHg from the transition zone to the LES. Herein, the mean DCI of 10 single swallows (SS) is compared with the DCI of MRS swallow. Based on the DCI metrics, the MRS patterns are classified as:

Normal: Ratio of MRS-DCI: SS-DCI >1[1],[3]

Type IEM-A: Ratio of MRS-DCI/SS-DC I: <1 and MRS-DCI >450 mmHg/s/Cm. This simulates normal motility.[4]

Type IEM-B: MRS-DCI <450 mmHg/s/Cm. IEM-B has greater reflux episodes, poor bolus transit, and prolonged esophageal clearance.[4]

MRS testing in mainly indicated for evaluation of ineffective peristalsis and peristaltic evaluation before fundoplication surgery. Variability is reported on consecutive MRS sequences and recent papers highlight that a minimum of 3 MRS maneuvers are needed to demonstrate a consistent pattern.[5] While a single MRS sequence may be sufficient in patients with normal motility, those with ineffective esophageal motility require at least 3 sets of MRS sequences.[6]

  Switching Supine to Upright Posture Top

Conventionally, HREM is done in the supine position to minimize the effect of gravitational force on esophageal peristalsis. However, testing in upright or standing position may be useful in a subset of patients. Separation between the LES and the crural diaphragm becomes less profound in the upright position, and small hiatus hernias may not be appreciated anymore. While testing esophageal motility in the upright position, the bolus transit is assisted by gravity and thus, obstructive motor findings that persist in the upright position are of clinical significance [Figure 2]. An integrated relaxation pressure (IRP) of >12 mmHg in the upright position correlates with significant esophageal outflow obstruction on fluoroscopic evaluation.[7] Thus, using upright swallows helps to better define obstructive disorders at EGJ, especially when IRP is high in asymptomatic patients in the supine position. However, the separation between the LES and the crural diaphragm becomes less pronounced in the upright position and one is more likely to miss small hiatus hernia.
Figure 2: Changes in esophageal motility in upright and supine positions in two patients

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  Changing Bolus Quantity and Consistency Top

Swallowing action is done in sitting or standing position in daily life using solid as well as liquids. Thus, majority of the patients experience symptoms pertaining to swallowing in these positions. However, HREM protocol consists of water swallows in a supine position only. Thus, it seems logical that one may get more information by altering bolus volume and consistency to replicate normal swallowing. This would help in replicating symptoms to evaluate motor patterns in relationship to symptoms. Rapid drink challenge [Figure 3] is one such test. It is done in sitting position and the patient is asked to drink 100–200 mL of fluid as fast as they can through a straw. The duration of time taken by the patient to complete the maneuver is recorded. The test is based on the principle that in normal individuals, repetitive swallowing leads to inhibition of esophageal peristalsis and profound relaxation of the LES. This converts the esophagus into a passive conduit for the flow of liquid to the stomach without resistance.[8] This test helps to identify latent EGJ outflow obstruction, especially when it is not evident in supine swallows. Outflow obstruction is characterized by panesophageal compartmentalization of pressure, or esophageal shortening and contraction.[9] IRP obtained by rapid drink challenge correlates with the severity of dysphagia.[10],[11],[12]
Figure 3: Rapid drink test - integrated relaxation pressure >12 mmHg, complete absence of normal peristalsis and esophageal shortening noted

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The administration of a standardized test meal provides for varied bolus consistency that replicates normal, day-to-day eating. Obstructive features may be better appreciated if the patient is asked to take a standard meal or food item that triggers symptoms.[13] These tests are useful in obstructive motility disorders. However, they are primarily used for research purposes and rarely in the clinical setting.

It has been noted that contraction vigor is increased on using solid swallows of bread or marshmallows in healthy volunteers as well as patients with reflux.[14] These are simpler to use and may yield more information.

  Postprandial Testing Top

Many patients have refractory reflux symptoms secondary to behavioral problems like rumination and supragastric belching.[15] In such cases, postprandial testing using high-resolution impedance manometry may provide a correct diagnosis.[16] Further, prolonged HREM monitoring may help identify transient LES relaxation.[17]

  Pharmacologic Provocation Top

This is mainly used for research purposes. The details of various drugs used and their utility are highlighted in [Table 1].[18],[19],[20]
Table 1: Drugs used in pharmacological testing of esophageal motility

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  The Current Status of Ancillary Testing Top

As per Chicago classification, 4.0, manometric and nonmanometric evaluation is required to arrive at a conclusive diagnosis of EGJ outflow obstruction (EGJOO). Apart from EGJOO, distal esophageal spasm and hypercontractile esophagus are the other two manometric patterns that must be accompanied by obstructive symptoms of dysphagia and/or non-cardiac chest pain to be considered clinically relevant. The latest Chicago classification version 4.0 recommends that manometry protocol should include supine and upright positions as well as additional manometric maneuvers-MRS and rapid drink challenges. Solid test swallows, postprandial testing, and pharmacologic provocation should be considered for particular conditions.[21]

In summary, MRS helps estimate peristaltic reserve to predict the risk of postfundoplication dysphagia. RDW unmasks latent EGJ outflow problems. Solid bolus study is recommended as provocative testing in select cases where the patient reports symptoms with this bolus type. Other techniques such as postprandial, prolonged, or drug effect HREM tests remain in the domain of research at present.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Fornari F, Bravi I, Penagini R, Tack J, Sifrim D. Multiple rapid swallowing: A complementary test during standard oesophageal manometry. Neurogastroenterol Motil 2009;21:718-e41.  Back to cited text no. 1
Gyawali CP, Kushnir VM. High-resolution manometric characteristics help differentiate types of distal esophageal obstruction in patients with peristalsis. Neurogastroenterol Motil 2011;23:502-e197.  Back to cited text no. 2
Shaker A, Stoikes N, Drapekin J, Kushnir V, Brunt LM, Gyawali CP. Multiple rapid swallow responses during esophageal high-resolution manometry reflect esophageal body peristaltic reserve. Am J Gastroenterol 2013;108:1706-12.  Back to cited text no. 3
Min YW, Shin I, Son HJ, Rhee PL. Multiple rapid swallow maneuver enhances the clinical utility of high-resolution manometry in patients showing ineffective esophageal motility. Medicine (Baltimore) 2015;94:e1669.  Back to cited text no. 4
Mauro A, Savarino E, De Bortoli N, Tolone S, Pugliese D, Franchina M, et al. Optimal number of multiple rapid swallows needed during high-resolution esophageal manometry for accurate prediction of contraction reserve. Neurogastroenterol Motil 2018;30:e13253.  Back to cited text no. 5
Jain M, Agrawal V. Evaluation of esophageal motor function in patients with gastroesophageal reflux using multiple rapid swallows. Indian J Gastroenterol 2021;40:241-8.  Back to cited text no. 6
Triggs JR, Carlson DA, Beveridge C, Jain A, Tye MY, Kahrilas PJ, et al. Upright integrated relaxation pressure facilitates characterization of esophagogastric junction outflow obstruction. Clin Gastroenterol Hepatol 2019;17:2218-26.e2.  Back to cited text no. 7
Marin I, Cisternas D, Abrao L, Lemme E, Bilder C, Ditaranto A, et al. Normal values of esophageal pressure responses to a rapid drink challenge test in healthy subjects: Results of a multicenter study. Neurogastroenterol Motil 2017;29:e13021.  Back to cited text no. 8
Marin I, Serra J. Patterns of esophageal pressure responses to a rapid drink challenge test in patients with esophageal motility disorders. Neurogastroenterol Motil 2016;28:543-53.  Back to cited text no. 9
Ang D, Hollenstein M, Misselwitz B, Knowles K, Wright J, Tucker E, et al. Rapid Drink Challenge in high-resolution manometry: An adjunctive test for detection of esophageal motility disorders. Neurogastroenterol Motil 2017;29:e12902.  Back to cited text no. 10
Biasutto D, Mion F, Garros A, Roman S. Rapid drink challenge test during esophageal high resolution manometry in patients with esophago-gastric junction outflow obstruction. Neurogastroenterol Motil 2018;30:e13293.  Back to cited text no. 11
Woodland P, Gabieta-Sonmez S, Arguero J, Ooi J, Nakagawa K, Glasinovic E, et al. 200 mL rapid drink challenge during high-resolution manometry best predicts objective esophagogastric junction obstruction and correlates with symptom severity. J Neurogastroenterol Motil 2018;24:410-4.  Back to cited text no. 12
Ang D, Misselwitz B, Hollenstein M, Knowles K, Wright J, Tucker E, et al. Diagnostic yield of high-resolution manometry with a solid test meal for clinically relevant, symptomatic oesophageal motility disorders: Serial diagnostic study. Lancet Gastroenterol Hepatol 2017;2:654-61.  Back to cited text no. 13
Daum C, Sweis R, Kaufman E, Fuellemann A, Anggiansah A, Fried M, et al. Failure to respond to physiologic challenge characterizes esophageal motility in erosive gastro-esophageal reflux disease. Neurogastroenterol Motil 2011;23:517-e200.  Back to cited text no. 14
Jain M, Agrawal V. Role of esophageal manometry and 24-h pH testing in patients with refractory reflux symptoms. Indian J Gastroenterol 2020;39:165-70.  Back to cited text no. 15
Yadlapati R, Tye M, Roman S, Kahrilas PJ, Ritter K, Pandolfino JE. Postprandial high-resolution impedance manometry identifies mechanisms of nonresponse to proton pump inhibitors. Clin Gastroenterol Hepatol 2018;16:211-8.e1.  Back to cited text no. 16
Mittal RK, Karstens A, Leslie E, Babaei A, Bhargava V. Ambulatory high-resolution manometry, lower esophageal sphincter lift and transient lower esophageal sphincter relaxation. Neurogastroenterol Motil 2012;24:40-6, e2.  Back to cited text no. 17
Cohen S, Fisher R, Tuch A. The site of denervation in achalasia. Gut 1972;13:556-8.  Back to cited text no. 18
Dalton CB, Hewson EG, Castell DO, Richter JE. Edrophonium provocative test in noncardiac chest pain. Evaluation of testing techniques. Dig Dis Sci 1990;35:1445-51.  Back to cited text no. 19
Richter JE, Hackshaw BT, Wu WC, Castell DO. Edrophonium: A useful provocative test for esophageal chest pain. Ann Intern Med 1985;103:14-21.  Back to cited text no. 20
Yadlapati R, Kahrilas PJ, Fox MR, Bredenoord AJ, Prakash Gyawali C, et al. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0©. Neurogastroenterol Motil 2021;33:e14058.  Back to cited text no. 21


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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