MANOMETRY Measurement Technique

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MANOMETRY Measurement Technique

• Jia-Feng Wu, M.D.
• Division of Gastroenterology,
• Department of Pediatrics,
• National Taiwan University Children Hospital

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Manometry at NTUH

• 1985

• 2007

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Manometry

• Anorectal manometry
• Esophageal manometry
• Antroduodenal manometry
• Oddi sphincter manometry

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Anorectal manometry

• Indication
• Equipment
• Preparation
• Investigation
• Analysis

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Anorectal manometry

• Indication
• Fecal incontinence
• Constipation
• Evaluation before-after operation
• Equipment
• Ano-rectal motility probe
• Recording device
• Computer
• Software

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Anorectal manometry

• Equipment
• Ano-rectal motility probe
• 3, 4, 6 or 8 channels
• Balloon
• Water perfused
• Micro-tip (not very common)

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Catheter

• Equipment
• Ano-rectal motility probe
• MicroTip catheter
• 1-4 channels
• Balloon mounting ring

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Preparation

• Preparation
• Patient must empty bladder and rectum. Enema only
  needed if patient has severe constipation
• Connect catheter to perfusion system
• Flush all channels to remove air-bubbles
• Zero balance catheter at anal sphincter level
• Introduce catheter in Anal sphincter/rectum
• Ready to start...

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Investigation

• Investigation
• Resting/Relax pressure
• Squeeze pressure
• Endurance squeeze
• Push/strain pressures
• Cough test
• RAIR
• Sensation test
• Vector Volume/Profile

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Resting

• Investigation
• Resting/Relax pressure
• Let the patient rest, no squeeze for 30 seconds
• Analyze average resting pressure in the high
  pressure zone (IAS and EAS)

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Squeeze

• Investigation
• Squeeze pressure
• Ask patient to squeeze for about 5 sec
• Wait 30 sec and repeat 3 times
• Analyze EAS contraction

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Endurated squeeze

• Investigation
• Endurance Squeeze
• Ask patient to squeeze for about 25 sec
• Analyze fatigue slope of EAS

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Push

• Investigation
• Push/Strain pressure
• Ask patient to strain like to defecate
• Pitfall embarrassment of patient
• Analyze EAS relaxation

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cough

• Investigation
• Cough test
• Ask patient to cough
• Analyze EAS contraction in response to sudden
  increase of abdominal pressure

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RAIR

• Investigation
• RAIR (Recto-Anal-Inhibitory-Reflex)
• Inflate balloon (20-50 mL or stepwise
  0-10-0-20-0-30-0-40-0-50 with air)
• Analyze IAS relaxation and spontaneous EAS
  response

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Sensation

• Investigation
• Sensation test
• Inflate balloon with air stepwise 10 ml (10, 20,
  30, 40...250 mL...until Max Vol)
• Wait 20-30 sec between inflation for
  accommodation of the rectum
• Ask patient sensation (No sensation, First
  sensation, urge, max Tolerable volume

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Normal data in children
lt 1m/o 1m/o-1y/o 1y/o-12y/o
Anal canal length (cm) 1.670.34 1.860.60 3.030.52
IAS (cmH20) 42.314.8 57.712.1 59.112.0
RAIR () 100 100 100
Mean volume for RAIR (ml) 9.673.6 14.09.5 25.011.6
J Pediatr Surg 2009441786-90
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Functional Constipation
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Hirschsprungs disease
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Intestinal neuronal dysplasia
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Spinal cord lipoma
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Esophageal manometry

• Anatomy
• Indication
• Equipment
• Preparation
• Investigation
• Analysis

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Esophageal manometry
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Esophageal manometryindication

• Primary esophageal motility disorders
• Achalasia
• Nutcracker esophagus
• Diffuse esophageal spasm
• Hypertensive LES
• Nonspecific Esophageal motility disorders
• Secondary esophageal motility disorders
• Scleroderma
• Diabetes mellitus
• Chronic idiopathic intestinal pseudo-obstruction
• Autoimmune disease

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Esophageal manometry -indications

• Determination of LES prior to pH investigation
• Pre-operative to exclude motility disorders for
  anti-reflux operations
• Dysphagia

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Catheter

• Equipment
• Esophageal motility probe
• 4-8 channels
• 5 cm spacing
• Sleeve at the tip

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catheter

• Equipment
• Esophageal motility probe
• MicroTip catheter
• 3-6 channels

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Preparation

• Preparation
• Patient must fast at least 6 hours
• Connect catheter to perfusion system
• Flush all channels to remove air-bubbles
• Zero balance catheter
• Lubricate catheter and introduce via the nose
• Ready to start...

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investigation

• Investigation
• LES
• Gastric baseline pressure
• LES resting pressure
• LES borders (location)
• LES relaxation during swallow
• Esophagus
• Esophageal motility (peristaltic contraction)
• UES
• Relaxation during swallow

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Steps

• All channels in stomach withdraw the catheter
  stepwise (0.5 cm/withdraw) and mark distances
• Look for the lower/upper border of the LES
• Position channels in esophagus and LES
• Let the patient swallow 10x (dry and wet swallow)
• Mark wet and dry swallows
• Optional UES

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interpretation

• Amplitude of primary peristalsis 487 mmHg
• secondary peristalsis
  465 mmHg
• Wave onset to peak (promixal) 1.90.1 secs
• 
  (distal) 1.80.1 mmHg
• Velocity of primary peristalsis 1.2-2.5 cm/s
• secondary
  peristalsis6.2-7.9 cm/s
• Percentage of abnormal wave lt 15 contractions
• 
  Am J
  Gastroenterol 2009104411-419

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normal
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Motility disorder

• Hypomotility Disorders
• Achalasia
• Hypermotility Disorders
• Diffuse Esophageal Spasm
• Hyperperistalsis
• Nutcracker
• Nonspecific Esophageal Motility Disorders

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Simultaneous contraction
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Esophageal spasm

• Manometry

• Esophagography

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Esophageal spasm

• Manometry findings
• Peristalsisgt30 abnormal contractions
• Duration and amplitude occasionally abnormal
• LES occasional hypertensive
• occasional incomplete relaxation

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Achalasia

• Manometry

• Esophageography

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Achalasia

• Esophageal manometry findings
• normal or increased resting pressure
  Incomplete or absent relaxation
• decreased distal contraction amplitude
• increased resting esophageal body pressure

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Nutcracker Esophagus

• Manometry

• Esophagography

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Nutcracker Esophagus

• Manometry findings
• Normal peristalsis
• Contraction amplitude is gt 2 SD above normal
  
• gt 180 mmHg in distal esophagus
• Duration of contractions gt6 sec.
• LES occasional hypertensive usually normal

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Achalasia and diffuse spasm
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Thanks