K. Bodger, N. Trudgill. Guidelines for oesophageal manometry and pH monitoring // BSG Guidelines in Gastroenterology. November 2006.

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Авторы: Bodger Keith / Trudgill Nigel


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EXECUTIVE SUMMARY & RECOMMENDATIONS

In patients with suspected oesophageal symptoms, flexible endoscopy and/or contrast radiology (eg. barium swallow) should be performed before considering manometric assessment (Evidence grade C).

Oesophageal manometry is indicated for the evaluation of dysphagia not definitively diagnosed by means of endoscopy and/or radiology, as manometry is the most accurate method for diagnosing the well-characterised primary oesophageal motility disorders (achalasia and diffuse oesophageal spasm) (Evidence grade C).

Oesophageal manometry is the most accurate method for pH electrode placement (Evidence grade B).

Acid gastro-oesophageal reflux accounts for a significant proportion of non-specific manometric abnormalities and a therapeutic trial of a proton pump inhibitor is recommended in the initial management of patients with suspected oesophageal symptoms, who have non-specific motility abnormalities identified at manometry (Evidence grade C)

Pre-operative oesophageal manometry is of limited value but does prevent anti-reflux surgery in the rare patients who present with clinical features suggestive of acid gastrooesophageal reflux and have a primary motility disorder, such as achalasia, and is therefore recommended (Evidence grade C).

In the absence of locally determined ranges for defining the limits of physiological acid reflux, the following data should be utilised: percentage total time oesophageal pH<4 <5%; percentage upright time oesophageal pH<4 <8%; percentage supine time oesophageal pH<4 <3%; number of episodes pH<4 for >5 minutes <3 (Evidence grade B).

Ambulatory oesophageal pH monitoring has clear limitations in defining pathological acid reflux due to false negative studies, but it is the only investigation that provides information on whether patients’ symptoms are related to acid reflux. The optimal period for analysis is from two minutes before to the time the event marker on the data logger was pressed (Evidence grade B). A measure of the association of the patient’s symptoms and acid reflux episodes, such as the symptom index, and the number of symptomatic events, should be included in the report of an ambulatory oesophageal pH study (Evidence grade C).

Ambulatory oesophageal pH monitoring has no role in the initial management of patients with symptoms suggestive of acid gastro-oesophageal reflux. A high dose therapeutic trial of a proton pump inhibitor is the diagnostic investigation of choice (Evidence grade B). In patients with symptoms suggestive of acid gastro-oesophageal reflux, who fail to respond during a therapeutic trial of a proton pump inhibitor, ambulatory oesophageal pH monitoring on a proton ump inhibitor may be of value to obviate the need for repeated, potentially futile, attempts at dose escalation (Evidence grade C).

Chest pain, throat and respiratory symptoms may be due to acid gastro-oesophageal reflux, particularly in patients with heartburn or acid regurgitation and no alternative explanation for their symptoms. A high dose therapeutic trial of a proton pump inhibitor is indicated in such patients (Evidence grade B). In patients with throat or respiratory symptoms this trial should be for four months, as a symptomatic response may be delayed (Evidence grade B). Ambulatory oesophageal pH monitoring off therapy may be of value to exclude excess acid gastro-oesophageal reflux when this appears unlikely or pH monitoring on a proton pump inhibitor may be of value when there is an inadequate response to a therapeutic trial, to judge whether further dose escalation is appropriate (Evidence grade C).

Patients with endoscopic oesophagitis and a good response to a proton pump inhibitor do not require an ambulatory oesophageal pH study prior to anti-reflux surgery. Patients with symptoms suggestive of acid reflux without endoscopic oesophagitis and a good response to a proton pump inhibitor should undergo ambulatory oesophageal pH monitoring off therapy prior to anti-reflux surgery (Evidence grade C).Patients with symptoms potentially due to acid reflux who fail to respond to a high dose proton pump inhibitor should undergo ambulatory oesophageal pH monitoring on a proton pump inhibitor prior to anti-reflux surgery and a good correlation between the patient’s symptoms and acid reflux episodes, as assessed by the symptom index, established (Evidence grade C). Ambulatory oesophageal pH monitoring should be undertaken in patients with persistent symptoms following anti-reflux surgery, particularly if further surgery is planned, to ensure there is evidence of persistent acid reflux and a good correlation between the patient’s symptoms and acid reflux episodes (Evidence grade C).

Oesophageal manometry and ambulatory oesophageal pH monitoring are associated with minor morbidity, largely vasovagal episodes, discomfort from the catheter and a runny nose, and restrictions affecting diet and activity. Patients with a heart valve replacement or a previous episode of bacterial endocarditis should receive antibiotic prophylaxis (Evidence grade C). All patients undergoing oesophageal manometry or ambulatory oesophageal pH monitoring should give written informed consent (Evidence grade C).

To ensure high clinical standards in oesophageal function testing, all clinicians undertaking oesophageal manometry or pH monitoring in the United Kingdom should be registered with the Association of Gastrointestinal Physiologists (AGIP) (Evidence grade C).



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