How the Body Position Can Influence High-resolution Manometry Results in the Study of Esophageal Dysphagia and Gastroesophageal Reflux Disease

Abstract

Background/AimsThe body position can influence esophageal motility data obtained with high-resolution manometry (HRM). To examine whether the body position influences HRM diagnoses in patients with esophageal dysphagia and gastroesophageal reflux disease (GERD).Methods HRM (Manoscan) was performed in 99 patients in the sitting and supine positions; 49 had dysphagia and 50 had GERD assessed by 24-hour pH monitoring. HRM plots were analyzed according to the Chicago classification. ResultsHRM results varied in the final diagnoses of the esophageal body (EB) in patients with dysphagia (P = 0.024), the result being more distal spasm and weak peristalsis while sitting. In patients with GERD, the HRM diagnoses of the lower esophageal sphincter (LES), the esophagogastric junction (EGJ) morphology, and EB varied depending on the position; (P = 0.063, P = 0.017, P = 0.041 respectively). Hypotensive LES, EGJ type III (hiatal hernia), and weak peristalsis were more frequently identified in the sitting position. The reliability (kappa) of the position influencing HRM diagnoses was similar in dysphagia and GERD ("LES diagnosis": dysphagia 0.32 [0.14-0

Prospective serial diagnostic study: the effects of position and provocative tests on the diagnosis of oesophageal motility disorders by high‐resolution manometry

“…By contrast, hypercontractile motility was diagnosed in four individuals in the supine and four non‐identical individuals in the upright position. This reflects the high degree of variability in contractile pressure reported by many authors, especially in the pathological range (Figure E, Figure S4B). Therefore, hypercontractile motility disorder should only be considered relevant if consistent and symptomatic.…”

“…The most striking finding was the change in peristaltic vigour (DCI) with position, with a mean 28% reduction in DCI in the upright compared to the supine position (Figure F). When upright, gravity facilitates passive movement of the bolus through the oesophagus into the stomach.…”

“…This finding explains, in part, the discrepancy in oesophago‐gastric junction outlet obstruction diagnosis between the two positions (see below). Not all authors have reported the same results . The reason for this discrepancy could be changes in intra‐gastric pressure (ie reference for HRM measurements) that occur on moving from the supine to the upright position, or the systematic change in gastric baseline pressure that occurs as the reference marker approaches the oesophago‐gastric junction reflux barrier …”

“…These limitations may, in part, be due to investigation in a nonphysiological position. Humans rarely drink or eat lying down and investigations in the upright position are easier to perform and favoured by patients . Additionally, symptoms are much more likely to occur with solid than liquid swallows and the use of protocols that assess only single water swallows will miss pathology such as outlet obstruction that may be apparent only on ingestion of solids …”

“…Humans rarely drink or eat lying down and investigations in the upright position are easier to perform and favoured by patients. 13,14 Additionally, symptoms are much more likely to occur with solid than liquid swallows and the use of protocols that assess only single water swallows will miss pathology such as outlet obstruction that may be apparent only on ingestion of solids. 15,16 Normative values for single water swallows in the upright position and for solid swallows using HRM have been published [16][17][18][19] and surveys indicate that many centres have adopted these techniques 20 ; however, it is not known how often there is diagnostic disagreement between measurements acquired in the upright and the established supine positions.…”