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MANOMETRY Measurement Technique

MANOMETRY Measurement Technique. Jia-Feng Wu, M.D. Division of Gastroenterology, Department of Pediatrics, National Taiwan University Children Hospital. Manometry at NTUH. 1985. 2007. Manometry. Anorectal manometry Esophageal manometry Antroduodenal manometry Oddi sphincter manometry.

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MANOMETRY Measurement Technique

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  1. MANOMETRY Measurement Technique Jia-Feng Wu, M.D. Division of Gastroenterology, Department of Pediatrics, National Taiwan University Children Hospital

  2. Manometry at NTUH 1985 2007

  3. Manometry • Anorectal manometry • Esophageal manometry • Antroduodenal manometry • Oddi sphincter manometry

  4. Anorectalmanometry • Indication • Equipment • Preparation • Investigation • Analysis

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

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

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

  8. 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…...

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

  10. 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)

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

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

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

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

  15. 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

  16. 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

  17. Normal data in children J Pediatr Surg 2009;44:1786-90

  18. Functional Constipation

  19. Hirschsprung’s disease

  20. Intestinal neuronal dysplasia

  21. Spinal cord lipoma

  22. Esophageal manometry • Anatomy • Indication • Equipment • Preparation • Investigation • Analysis

  23. Esophageal manometry

  24. 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

  25. Esophageal manometry -indications • Determination of LES prior to pH investigation • Pre-operative to exclude motility disorders for anti-reflux operations • Dysphagia

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

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

  28. 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…...

  29. 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

  30. 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

  31. interpretation • Amplitude of primary peristalsis: 48±7 mmHg secondary peristalsis: 46±5 mmHg • Wave onset to peak (promixal): 1.9±0.1 secs (distal): 1.8±0.1 mmHg • Velocity of primary peristalsis: 1.2-2.5 cm/s secondary peristalsis:6.2-7.9 cm/s • Percentage of abnormal wave: < 15% contractions Am J Gastroenterol 2009;104:411-419

  32. normal

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

  34. Simultaneous contraction

  35. Esophageal spasm Manometry Esophagography

  36. Esophageal spasm • Manometry findings: Peristalsis:>30% abnormal contractions Duration and amplitude occasionally abnormal LES: occasional hypertensive; occasional incomplete relaxation

  37. Achalasia Manometry Esophageography 37

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

  39. Nutcracker Esophagus Manometry Esophagography

  40. Nutcracker Esophagus • Manometry findings: Normal peristalsis Contraction amplitude is > 2 SD above normal > 180 mmHg in distal esophagus Duration of contractions >6 sec. LES: occasional hypertensive; usually normal

  41. Achalasia and diffuse spasm

  42. Thanks

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