Upload
others
View
5
Download
0
Embed Size (px)
Citation preview
Manometry
“Manometry is a diagnostic test that measures changes in intraluminal pressure
and the coordination of activity in the muscles of the GI tract.” 1
1 Amy Carpenter Aquino, ed. Gastroenterology Nursing: A Core Curriculum, 4th edition ("n.p."
Society of Gastroenterology Nurses and Associates, Inc. 2008) 319.
Learning Objectives
After attending this presentation, the learner will be able to:
Describe the general principles, equipment and procedures typically employed in manometry studies.
List the types of manometry: Esophageal, stomach and small bowel,
Sphincter of Oddi and anorectal. Their indications and contraindications.
Discuss the manometry patterns of normal subjects and common abnormal studies.
Describe an awareness of Chicago Classification editing and Impedance
Studies.
Three components to the equipment for any manometry:
•Probe with sensors - positioned in the lumen you are testing.
•Transducer - a device that transforms a pressure value into an electrical signal
•Computer or physiography – a system that displays a graphic image for editing and interpretation
Types of Manometry
•Esophageal
•Gastroduodenal small bowel
•Sphincter of Oddi
•Anorectal
Esophageal manometry
Anatomy
Physiology
Primary versus secondary peristalsis
Graphic view of secondary peristalsis
Indications for Esophageal Manometry 2
•Dysphagia
•Non-cardiac chest pain
•Pre-operative evaluation for anti-reflux surgery
•GERD
•Determine location of LES for placement of pH probe
•Evaluate diseases affecting the GI tract such as scleroderma
•Exclude esophageal etiology for suspected anorexia
2 Aquino 319
Contraindications for Esophageal Manometry
•Uncooperative patients
•Recent gastric surgery
• Severe esophageal ulcers
•Known obstruction
•Recent administration of sedatives or narcotics
•BRAVO pH study within 2 weeks
Esophageal Manometry solid state probe
High Resolution 32 sensor Manometry Probe
3 Smith, Paulette, "High Resolution Impedance Manometry" On-site Training Manual, Sandhill
Scientific, Highlands Ranch, CO, LaCrosse, 30 Jan. 2015.
Graph recording of Esophageal Manometry
Normal Values for Esophageal Manometry 4
•Esophageal body amplitude: 30 – 180 mmHg
•Lower esophageal sphincter resting pressure: 10 – 45 mmHg
•Lower Esophageal relaxation pressure: < 8 mmHg.
4 Smith
Achalasia5
5 Smith
Graphic view of Achalasia
Distal Esophageal Spasm (DES)6
6 Smith
Nutcracker Esophagus 7
7 Smith
Nutcracker
Jackhammer
Ineffective Esophageal Motility (IEM) 8
8 Smith
Scleroderma 9
9 Smith
Provocative Testing to reproduce symptoms
•Bernstein Test – Water infused manometry probe with alternating infusions of saline and hydrochloric acid. Test is positive if patient reports feelings of heartburn. Test not used much with 24 hour Ph testing methods now available
•Tensilon (edrophonium, a short acting cholinesterase inhibitor) – With manometry probe in place in esophagus, IV injection of saline placebo alternating with Tensilon. Test is positive if patient reports same type of chest pain.
Gastroduodenal/small bowel manometry
• Symptoms of delayed gastric emptying:
• Severe gastric retention
•Nausea and vomiting
•Weight loss
•Not used very much except in research as other gastric emptying studies with radioisotope tagged foods are more common
Gastroduodenal Small Bowel Manometry
• Stomach – fundus, body, antrum
•Gastric pacemaker in middle of gastric body
•3 peristaltic waves per minute
•16 to 20 feet small intestine. Short, propulsive movement mixes chyme with intestinal secretions toward cecum.
•Probe placed endoscopically - test may last several hours
•Mostly in larger motility centers and for research
Sphincter of Oddi Manometry
10 Anthony, Catherine Parker, and Norma Jane Kolthoff, Textbook of Anatomy and Physiology St.
Louis: CV Mosby, 1971 p. 404.
Sphincter of Oddi Procedure
Indications
•Abdominal pain
•Elevated liver enzymes
•Dilated common bile duct
Contraindications
•Acute pancreatitis
•Barium in GI tract
•Pregnancy
• Inability to tolerate anesthesia
Anorectal Manometry
Solid State anorectal probe
11 Reveille, R. Matthew, and Linda Knight, "Anorectal Manometry: Advanced Interpretation"
Anorectal Interpretation Seminar, Sandhill Scientific, Crowne Plaza Chicago O'Hare, Chicago 20 Oct. 2006.
Air infused disposable probe
Balloon inflated / 4 directional sensors
12 Reveille, R. Matthew, and Linda Knight, "Anorectal Manometry Basic Concepts" Anorectal Interpretation Seminar, Sandhill Scientific, Crowne
Plaza Chicago O'Hare, Chicago, 20 Oct. 2006.
Anorectal Manometry
Indications•Constipation
• Fecal incontinence
•Rectal/Anal pain
•Pre-surgical evaluation
•Rule out Hirshsprung's Disease,
•Chagas’ Disease
Contraindications•Uncooperative patient
•Patient unable to tolerate due to pain with probe inserted
• Infectious diarrhea
Preparation and Patient Instruction
•Procedure takes about 60 minutes (less in infants)
•Prepare with 2 fleets enemas
•No sedation involved
•Pt awake and lying on left side with parts of the test passive and parts interactive
• Study consists of six phases with instructions before each
•Once probe is out, no restrictions or post care needed
Anatomy of rectum and anal sphincter
13 Reveille, Anorectal Manometry: Basic Concepts
Six steps of the testing
•Resting pressure Study
•Squeeze Study
•Squeeze Duration
•RAIR – Rectoanal Inhibitory Reflex
•Push (Strain) Study
•Rectal Compliance Study
Resting pressure pull through
Rectoanal Inhibitory Response
Push (Strain) Maneuver
Normal values 14
•Sphincter length: Male - 3-4 cm Female - 2.5-3 cm
•Normal sphincter resting pressure: 50 - 120 mmHg
•Normal squeeze pressure is < 100 mmHg above resting pressure (Desirable to have at least 100 mmHg to maintain continence.)
•RAIR – At least a 15 % drop in resting pressure. Begins at 10cc, complete at 60 cc
14 Aquino
Normal Sensation Thresholds
• First sensation – 10 cc (15 cc over age 65)
•Urge sensation – 80-100 cc
•Maximum tolerance – we stop filling balloon at 200 cc
15 Reveille
•Chicago Classification of Esophageal Motility Disorders
•Impedance Manometry and 24 pH Impedance testing
Bibliography1. Anthony, Catherine Parker, and Norma Jane Kolthoff. Textbook of Anatomy and Physiology. 8th ed. St. Louis: C.V. Mosby, 1971.
2. Aquino, Amy Carpenter. Gastroenterology Nursing: A Core Curriculum. 4th ed. N.p.: Society of Gastroenterology Nurses and Associates, 2008.
3. Griffin, Vanessa. Gastroenterology Nursing: A Core Curriculum. 3rd ed. N.p.: Society of Gastroenterology Nurses and Associates, 2003.
4. Groer, Maureen E., and Maureen E. Shekleton. Basic Pathophysiology: A Conceptual Approach. St. Louis: C.V. Mosby, 1979.
5. Kahrilas, P.J., et al. “The Chicago Classification of esophageal motility disorders, v3.0”. Neurogastroenterology & Motility 27 (2015): 160-174.
6. O’Connor, Wendy. “Chicago Classifications”. Conference call with shared computer network access. Sandhill Scientific. Highlands Ranch, CO. LaCrosse, WI 17 Mar. 2015.
7. Reveille, R. Matthew, and Linda Knight. “Anorectal Manometry: Advanced Interpretation”. Anorectal Interpretation Seminar, Sandhill Scientific. Chicago: 20 Oct. 2006.
8. Reveille, R. Matthew, and Linda Knight. “Anorectal Manometry: Basic Concepts”. Anorectal Interpretation Seminar, Sandhill Scientific. Chicago: 20 Oct. 2006
9. Schuster, Marvin M., Michael D. Crowell, and Kenneth L. Koch. Schuster Atlas of Gastrointestinal Motility in Health and Disease. 2nd ed. Hamilton, Ont.: BC Decker, 2002.
10. Smith, Paulette. “High Resolution Impedance Manometry”. On-Site Training, Sandhill Scientific, Highlands Ranch, CO. LaCrosse, WI 30 Jan. 2015.
Bike ride across the Mississippi
Are you ready for some FOOTBALL????