Investigation of oesophageal disorders, including 24 hour pH monitoring, oesophageal manometry, nuclear medicine transit study, and barium swallow
Four questions, four tests
- Four questions, four tests - choose by the question, not by habit
| Question | Test |
|---|---|
| Mucosa? (oesophagitis, Barrett, stricture, EoE, malignancy) | Endoscopy + biopsy |
| Motility? (achalasia, spasm, scleroderma) | High-resolution manometry |
| Is it reflux? (and is the symptom reflux-related) | 24h pH-impedance off/on PPI |
| Anatomy, dynamic swallow, aspiration | Barium swallow / videofluoroscopy |
- Nuclear (scintigraphic) transit - gastro-oesophageal reflux scan, oesophageal transit, gastric emptying
- Niche; quantifies transit and detects aspiration in children and neurological disease
Epidemiology
- GORD symptoms: ~15-20% of Western adults weekly
- Achalasia: 1-2 per 100,000/yr, no sex predilection, peak 30-60
- Eosinophilic oesophagitis: rising sharply; commonest cause of food bolus obstruction in young men
- Endoscopy is normal in ~50-70% of symptomatic GORD (non-erosive reflux disease)
What the tests are measuring
- LOS - tonic contraction, relaxes with swallow
- Transient LOS relaxations = dominant mechanism of physiological and most pathological reflux, not low resting tone
- Peristalsis - primary (swallow-initiated), secondary (distension-initiated)
- Achalasia - loss of inhibitory myenteric neurons (NO, VIP)
- -> failure of LOS relaxation + aperistalsis
- Antireflux barrier - LOS + crural diaphragm + angle of His; hiatus hernia separates the two components -> reflux
Endoscopy
A. Endoscopy
- Indicated when: alarm features (dysphagia, weight loss, GI bleeding, vomiting, anaemia), age >60 with new dyspepsia, or suspected erosive oesophagitis, stricture or Barrett's
- Barrett's is the pre-malignant complication - endoscopy is how it is found
- Biopsy protocol matters: EoE needs >=6 biopsies from proximal AND distal oesophagus (>=15 eos/hpf)
- Los Angeles grading of oesophagitis A-D
- *LA grade C/D, biopsy-proven Barrett's, or peptic stricture = conclusive GORD - no pH study needed*
- Do not biopsy/dilate before considering EoE; and stop PPI 2-4 weeks before a diagnostic reflux endoscopy where feasible
Barium swallow / videofluoroscopy
B. Barium swallow / videofluoroscopy
- Best for structure and dynamics, not mucosa
- Findings:
- Achalasia - bird's beak tapering, dilated aperistaltic body, air-fluid level
- Strictures - length, calibre, position (peptic = distal, short; malignant = irregular shouldered)
- External compression - vascular ring, mediastinal mass, aberrant subclavian (dysphagia lusoria)
- Duplication cysts
- Pouches/rings - Zenker diverticulum, Schatzki ring, webs
- Videofluoroscopic swallow study - oropharyngeal dysphagia, aspiration, penetration; done with speech pathology
- Timed barium swallow quantifies emptying - used to follow achalasia after treatment
High-resolution manometry - Chicago Classification v4.0
C. High-resolution manometry - Chicago Classification v4.0
- Mandatory before antireflux surgery and before achalasia therapy
- Key metrics: IRP (integrated relaxation pressure - LOS relaxation), DCI (contractile vigour), DL (distal latency)
- v4.0 requires supine AND upright swallows plus provocative testing (multiple rapid swallows, rapid drink challenge)
| IRP | Body | |
|---|---|---|
| Achalasia type I | inc | No contractility |
| Achalasia type II | inc | Pan-oesophageal pressurisation - best response to any therapy |
| Achalasia type III | inc | Spastic (premature, dec DL) - worst response to dilatation; POEM preferred |
| EGJ outflow obstruction | inc | Peristalsis preserved - v4.0 now requires corroborative imaging; many are artefact or opioid-related |
| Distal oesophageal spasm | normal | >=20% premature (dec DL <4.5 s) |
| Hypercontractile (jackhammer) | normal | DCI >8000 |
| Absent contractility | normal | 100% failed - scleroderma: absent contractility + hypotensive LOS |
| Ineffective oesophageal motility | normal | >70% ineffective or >=50% failed (threshold raised in v4.0) |
- *Opioids cause a manometric picture indistinguishable from type III achalasia / EGJOO - always ask*
Ambulatory reflux monitoring (pH or pH-impedance)
D. Ambulatory reflux monitoring (pH or pH-impedance)
- Off PPI (7 days) - to establish whether GORD exists at all (unproven GORD, before surgery)
- On PPI - to explain persisting symptoms despite treatment, and to check adequacy of acid suppression
- Impedance adds non-acid and gas reflux - essential for on-PPI studies and for rumination/belching disorders
- Acid exposure time (AET)
| AET | Interpretation |
|---|---|
| <4% | Normal - reflux not the cause |
| 4-6% | Inconclusive - use adjuncts (MNBI, PSPW) |
| >6% | Conclusive pathological reflux |
- Symptom association: symptom index (SI) >=50% and symptom association probability (SAP) >=95%
- Correlates cough, apnoea, stridor, asthma, chest pain with reflux episodes
- Wireless (Bravo) capsule - 48-96 h, better tolerated, no impedance
- A normal study off PPI in a symptomatic patient -> functional heartburn or reflux hypersensitivity, not GORD
Laryngotracheobronchoscopy
E. Laryngotracheobronchoscopy
- Extra-oesophageal reflux: vocal cord nodules, posterior laryngitis, silent aspiration
- Laryngoscopic signs alone are non-specific - do not treat "LPR" on them without objective reflux testing
Nuclear studies
F. Nuclear studies
- Gastro-oesophageal reflux scintigraphy - quantifies reflux, detects pulmonary aspiration
- Oesophageal transit scintigraphy - non-invasive transit time; useful where manometry is not tolerated
- Gastric emptying study - when gastroparesis mimics or coexists
What the result changes
- Achalasia confirmed -> pneumatic dilatation, laparoscopic Heller myotomy, or POEM
- Type III -> POEM (longer myotomy); type II -> any works; type I -> consider dilated/sigmoid oesophagus
- Botulinum toxin only if unfit for definitive therapy (wears off in 6-12 months)
- Conclusive GORD (AET >6% or LA C/D or Barrett's or stricture) -> PPI, weight loss, then consider fundoplication or magnetic sphincter augmentation
- *Never operate on reflux without pre-op manometry* - a missed achalasia or absent contractility turns a wrap into dysphagia
- Normal AET + negative symptom association -> functional heartburn -> neuromodulator (low-dose TCA), not more acid suppression
- Normal AET + positive symptom association -> reflux hypersensitivity
- EoE on biopsy -> PPI, swallowed topical corticosteroid (budesonide orodispersible), elimination diet, dupilumab
- Peptic stricture -> dilatation + lifelong PPI
- Ineffective motility / scleroderma -> aggressive antireflux therapy, avoid full wrap
Monitoring uses
- pH study on therapy to confirm acid suppression is adequate before escalating
- Timed barium swallow to follow achalasia post-treatment
- Endoscopic surveillance for Barrett's
Associations
- Scleroderma/CREST - absent contractility + patulous LOS -> severe GORD, stricture, Barrett's
- Eosinophilic oesophagitis - atopy, food bolus obstruction
- Opioid use - opioid-induced oesophageal dysfunction mimicking achalasia
- Chagas disease - achalasia phenotype
- Pseudoachalasia - GOJ malignancy, suspect if age >60, rapid weight loss, short history
- Hiatus hernia - separates LOS from crural diaphragm
- Obesity, pregnancy, smoking - GORD
- Neurological disease and stroke - oropharyngeal dysphagia on videofluoroscopy
- Zenker diverticulum, Schatzki ring
Achalasia natural history
- Untreated achalasia -> progressive dilatation -> sigmoid/megaoesophagus -> oesophagectomy
- Squamous cell carcinoma risk inc ~16-30x, typically after 10-20 years
- Treatment relieves obstruction but does not restore peristalsis or remove cancer risk
- GORD -> erosive oesophagitis -> peptic stricture, Barrett's oesophagus -> dysplasia -> adenocarcinoma
- Post-fundoplication - dysphagia, gas-bloat, inability to belch/vomit; wrap failure over time
- Post-POEM - reflux in ~30-50%, often asymptomatic -> surveillance endoscopy warranted
- EoE untreated -> fibrostenotic remodelling -> fixed strictures
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