The Clinical Utility of Provocative Maneuvers at Esophageal High-resolution Manometry (HRM)

Esophageal Motility Disorders: A Concise Review on Classification, Diagnosis, and Management

Esophageal motility disorders (EMDs) are an underrecognized cause of dysphagia and encompass a breadth of conditions, including achalasia, esophagogastric junction outflow obstruction, absent contractility, distal esophageal spasm, hypercontractile esophagus, and ineffective esophageal motility. Whereas patients with EMDs classically present with dysphagia to both solids and liquids, other symptoms such as heartburn, noncardiac chest pain, and regurgitation may also be present. The advent and standardization of high-resolution esophageal manometry by the Chicago Classification have revolutionized the diagnosis and management of EMDs. The EMDs are broadly classified into disorders of the esophagogastric junction (achalasia, esophagogastric junction outflow obstruction) and peristalsis (absent contractility, distal esophageal spasm, hypercontractile esophagus, ineffective esophageal motility). Additional tests, such as timed barium esophagogram and EndoFLIP, can help provide adjunctive information in cases in which high-resolution esophageal manometry findings are inconclusive. Management varies widely according to the type of EMD and can range from lifestyle and dietary modifications to oral pharmacologic therapy and various endoscopic or surgical interventions. In patients with achalasia, durable management aimed at the lower esophageal sphincter should strongly be considered. This clinical review aims to provide a concise yet comprehensive summary on classification, diagnosis, and management of EMDs.

Gastroesophageal Reflux Disease

Symptoms potentially attributable to gastroesophageal reflux disease are among those most commonly reported to primary care providers in the outpatient setting. In this review, we discuss clinical approaches to the evaluation and management of these symptoms, including proton pump inhibitor trials as well as specific indications or clinical settings that warrant referral to Gastroenterology specialists.

Novel Diagnostic Techniques in the Evaluation of Gastroesophageal Reflux Disease (GERD)

In our present clinical paradigm, patient symptoms and presentation in the setting of traditional findings from endoscopy (erosive esophagitis, Barrett's esophagus, reflux-mediated stenosis), esophageal high-resolution manometry, and/or ambulatory reflux monitoring (distal esophageal acid exposure time, numbers of reflux events, reflux-symptom association) guide the care of patients with suspected GERD. However, novel metrics and techniques acquired from or performed at endoscopy, manometry, or pH-impedance monitoring, beyond conventional evaluation, are of great interest to the gastroenterology community given the frequent (and sometimes challenging) presentation of suspected GERD. These novel and evolving diagnostic approaches have the potential to enhance the evaluation of these patients and optimize their management. In this invited review, we discuss the present evidence and potential clinical utility of selected GERD metrics and techniques of interest at endoscopy (dilated intercellular spaces, mucosal impedance), manometry (contractile integral, impedance analysis, straight leg raise, multiple rapid swallow maneuvers), and reflux monitoring (mean nocturnal baseline impedance, post-reflux swallow-induced peristaltic wave indices), and how these tools may be most optimally adopted and utilized for clinical care (Fig. 1).