ACG Publishes Clinical Guidelines on Esophageal Physiologic Testing
The American College of Gastroenterology (ACG) has developed 11 key concepts and 16 recommendations for esophageal physiologic testing for patients with obstructive symptoms, motility disorders, achalasia, and symptoms of gastroesophageal reflux disease (GERD.)
Among its strong recommendations is the use of high-resolution esophageal manometry (HRM) over conventional line tracing in evaluating patients with symptoms of esophageal obstruction. In its key concepts, the ACG stated that HRM is an important diagnostic procedure in ruling out motility disorders and evaluating esophageal peristalsis in patients with symptoms of GERD. HRM should be performed before antireflux surgery or other invasive management procedures for GERD, the guidelines state, adding the caution that HRN cannot, by itself, diagnose GERD.
The guidelines further noted that based on current data, it appears that HRM has a higher sensitivity for detecting hiatus hernia compared with either endoscopy or barium radiography. “However, because of varying performance characteristics, the 3 studies are complementary,” the document states.
One of the key concepts advanced in the guideline is that “barium esophagography provides information about bolus clearance in patients with dysphagia,” while high-resolution impedance manometry (HRIM) “provides adjunctive information about bolus clearance.”
A study that compared HRIM and barium esophagram for measuring bolus clearance in 20 patients with achalasia showed that “impedance-barium esophagram concordance was found to be high for swallows with normal esophageal emptying and for severe barium stasis.”
The ACG also recommends “the use of functional lumen imaging probe (FLIP) to complement HRM for the diagnosis of esophageal motility disorders in patients with obstructive esophageal symptoms and borderline HRM findings.” This conditional recommendation states that FLIP topography can be helpful in diagnosing motility disorders when manometry studies cannot be completed, such as when catheter placement fails.
FLIP also can be used to help direct invasive treatments for achalasia and to predict clinical outcomes of these treatments, the guideline states, though the precise protocols for the use of FLIP in some treatments require further research and development.
In addition, the guidelines state, “FLIP may be considered for measurement of distensibility to assess fibrostenotic remodeling of the esophagus and stratify risk of food impaction in patients” with eosinophilic esophagitis (EoE). Noting that FLIP has shown utility as a marker for esophageal remodeling in patients with EoE, the guidelines add that “further research is needed before this indication for FLIP can become a part of routine clinical care in EoE.”
Patient-reported outcome (PRO) scores are useful for follow-up after treatment for achalasia, the guidelines state, but “analysis suggests only fair psychometric performance, with particular weakness related to the chest pain and weight loss items. In addition, discordance is sometimes observed between symptom severity and objective esophageal function” following treatment for achalasia.
The guidelines also include recommendations on physiologic testing methods for assessing patient response to proton pump inhibitor therapy and for diagnosing rumination syndrome, supragastric belching, and other disorders.
“Proper test selection, with understanding of test performance characteristics and limitations, can help identify disease processes and predict symptom outcome from management,” the guidelines state. “Prospective high-quality studies using multiple modalities of esophageal tests for symptomatic patients are needed to understand the true value of each physiologic test in predicting outcome.”
—Rebecca Mashaw
Reference:
Gyawali CP, Carlson DA, Chen JW, Patel A, Wong RJ, Yadlapati RH. ACG clinical guidelines: clinical use of esophageal physiologic testing. Am J Gastroenterol. 2020;115(9):1412-1428.
