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New guidelines set standard on test to diagnose acid reflux, heartburn and other diseases

December 04, 2003

New consensus guidelines will help to set the standards for physicians using esophageal manometry to accurately identify esophageal diseases such as gastroesophageal reflux disease, heartburn, problems with swallowing or non-heart related chest pain coming from the esophagus.

Although a test called esophageal manometry has provided the best diagnostic tool for healthcare professionals to diagnose suspected diseases of the esophagus, there are no uniform standards to guide physicians as to the best way to perform the procedure or to interpret the results. In fact, a lack of standardized training and multiple ways to perform the test have made it difficult or impossible to share data between physicians.

Now, new consensus guidelines will help to set the standards for physicians using esophageal manometry to accurately identify esophageal diseases such as gastroesophageal reflux disease, heartburn, problems with swallowing or non-heart related chest pain coming from the esophagus. The paper is published in the December issue of Neurogastroenterology and Motility.

"This is the first paper to provide a detailed standardized description of how esophageal manometry should be administered. It will help clinical practitioners to perform a standardized and reproducible test that can be interpreted across the board by other doctors," said Dr. Jeffrey L. Conklin, Medical Director of the Esophageal Center at Cedars-Sinai Medical Center in Los Angeles.

The esophagus is a muscular tube that connects the throat with the stomach. Its synchronized contractions push what is swallowed into the stomach. At the upper and lower ends of the esophagus are two short areas of specialized muscle called the upper and lower esophageal sphincters. When at rest, the muscles of the upper and lower esophageal sphincters are closed and prevent anything from passing through them. For example, the upper sphincter prevents food or liquid within the esophagus from backing up into the throat, while the lower esophageal sphincter protects the lower esophagus from stomach acid and bile by opening only when food or liquid is swallowed.

When a person is afflicted with esophageal problems such as acid reflux, heartburn, swallowing problems or chest pain, doctors use esophageal manometry to determine how well the muscle of the esophagus works. The information can then help them to identify and treat the problem.

During the procedure, a thin, flexible plastic catheter with very small openings that are located at varying positions along the tube is placed down the esophagus through the patient's nostril. These openings sense the pressure in various parts of the esophagus when the muscle is at rest and during swallowing. The pressures are then transmitted to a computer analyzer where they are recorded. The doctor then analyzes the various wave patterns and determines whether they are abnormal.

"Although esophageal manometry has been around for at least two decades, most gastroenterologists continue to see it in somewhat mystical terms. This is because few practitioners are sufficiently trained in the principles and practice of manometry, and because performance of the test was never adequately standardized. Our goal was to give clinicians some background about the principles of esophageal manometry, and to give them a detailed standard approach to performing and reporting the test," said Dr. Conklin.

In the paper, Dr. Conklin and his colleagues describe how the esophagus works in varying disease states, the proper way to study it using esophageal manometry, and also identify the abnormalities that cause diseases of the esophagus. These include achalasia, where the nerves are damaged; esophageal spasms; non-cardiac chest pain; a condition called scleroderma, or chronic autoimmune disease of the connective tissue; and hiatal hernia, which occurs when a part of the stomach slides above the diaphragm, the thin muscle separating the stomach from the chest.

Jeffrey L. Conklin, M.D., Medical Director of the Esophageal Center at Cedars-Sinai Medical Center

J.A. Murray, M.D., Director of the Esophageal Unit at the Mayo Clinic, Rochester MN

R.E. Clouse, M.D., Professor of Medicine, Washington University School of Medicine, Saint Louis. MO.

Cedars-Sinai Medical Center

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