High resolution manometry uses more sensors spaced closer together than conventional manometry to provide spatiotemporal colour representations of pressure along the esophagus. It is used to evaluate esophageal motility by assessing relaxation of the lower esophageal sphincter, integrity of peristaltic waves, location and timing of the contractile deceleration point, propagation and strength of contractions, and abnormal pressure patterns that may indicate conditions like achalasia. A manometry protocol involves positioning sensors in the esophagus and having the patient swallow to record pressure measurements during various tasks in supine and upright positions.

1. Esophageal Manometry

2. Conventional Manometry
• Widely spaced sensors
• Only line representation
• No coloured dynamic representations

3. Manometry Sensors

4. High Resolution Manometry
• Ray Clause
• >12 sensors, spaced <2 cm apart
• Spatiotemporal colour- pressure-length- time plots
• Expensive

6. Instructions
• NPO for minimum 4 hours
• Consent, explain procedure
• Numb nostril with 2% Xylocaine gel
• Lubricated catheter inserted transnasally

8. Manometry Protocol (Chicago v4.0)
Supine Position Upright Position
>=60 sec adaptation period >=60 sec adaptation period
3 deep inspirations to document position 3 deep inspirations to document position
>=30 sec baseline period (for landmarks) >=30 sec baseline period
10 supine wet (5 ml) swallows >=5 upright wet (5 ml) swallows
1 multiple rapid swallow 1 rapid drink challenge

9. EPT

10. Step 1- Assess EGJ Relaxation - IRP
• A measure of deglutitive relaxation across LES/EGJ
• Average lowest pressure through EGJ for 4 contiguous or non-contiguous
seconds within 10-second window following deglutition
• Abnormal- supine median IRP>15 mmHg (Medtronic)

12. Step 2- Assess Integrity of Peristaltic Wave
• Transition zone
• Peristaltic breaks
• Ineffective swallows - break>5 cm

14. Step 3- Determine Location of CDP
• Elbow of contraction
• Inflection point along the contractile wavefront where greatest
deceleration occurs
• Associated with maximal axial contraction of esophageal body

16. Step 4- Assess Propagation - DL
• Distal latency- measures time frame from beginning of swallow to CDP
• Indirect measurement of deglutitive inhibition
• Normal >=4.5 seconds
• Premature/Spastic contraction: DL <4.5 seconds in setting of a DCI
≥450 mmHg·s·cm, in DES

17. DES

18. Step 5- Measure Contractile Vigor- DCI
• Distal Contractile Integral
• Measure of peristaltic vigor in esophageal smooth muscle
• Amplitude × duration × length (mmHg x s x cm) of the distal esophageal
contraction exceeding 20 mmHg from transition zone to proximal margin of LES

20. Distal Contractile Integral
Normal - 450-8,000 mmHg.s.cm
Weak - >100 and <450 mmHg.s.cm
Failed Peristalsis- <100 mmHg.s.cm
Hypercontractile - >8,000 mmHg.s.cm

21. Jackhammer Esophagus

22. Step 6- Assess Abnormal Pressure Patterns
• Compartmentalised- between peristalsis and EGJ, in EGJ obstruction
• Pan-esophageal pressurisations- between two sphincters, type II
achalasia

23. Pan-esophageal Pressurisations

24. Achalasia