Evaluation of Indications of Patients referred to Ambulatory Oesophageal Manometry & 24-hour Impedance pH monitoring in University Hospital Kaunas Clinics in 2018-2019

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1 LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

FACULTY OF MEDICINE

DEPARTMENT OF GASTROENTEROLOGY

Evaluation of Indications of Patients referred to Ambulatory

Oesophageal Manometry & 24-hour Impedance pH monitoring in

University Hospital Kaunas Clinics in 2018-2019

Author: Jane Velda Crasto

Supervisor: Jaune Ieva Lukosiene, M.D.

Consultant: Laimas Virginijus Jonaitis, M.D., Ph.D., Prof.

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ABSTRACT

Author name: Jane Velda Crasto

Title:

Evaluation of Indications of Patients referred to Ambulatory Oesophageal Manometry & 24-hour Impedance pH monitoring in University Hospital Kaunas Clinics in 2018-2019.

Aim: To analyse indications used for referring patients for ambulatory Oesophageal

Manometry & 24-hour Impedance pH monitoring in University Hospital Kaunas Clinics in 2018-2019 and to compare them to the indications recommended by the clinical guidelines.

Objectives:

● To review the existing literature in the field of functional gastrointestinal testing and to comprehend clinical scenarios in which these methods are adaptable.

● To evaluate clinical cases in which patients were referred for oesophageal manometry and 24-hour Impedance pH monitoring in University Hospital Kaunas Clinics in 2018-2019.

● To compare the indications used for referral for oesophageal manometry and 24-hour Impedance pH monitoring in University Hospital Kaunas Clinics in 2018-2019 to indications recommended by the guidelines.

Methodology: The study was conducted at the University Hospital Kaunas Clinics. It

included adult patients referred for routine oesophageal manometry and 24-hour Impedance pH monitoring in 2018-2019. Indications used for referral for oesophageal manometry and 24-hour Impedance pH monitoring were identified and analysed. The quantitative analysis was performed using Statistical Package for the Social Sciences (SPSS version 24.0, SPSS Inc., Chicago, IL, USA). The overall number and percentage of total sample size were

reported for each indication. Indications used for referral were compared to the indications recommended by the clinical guidelines. The outcome of each individual investigation was assessed and the ratio between proven and unproven diagnosis was evaluated.

Research Participants: Adult patients referred for oesophageal manometry (n=108) and

Impedance pH monitoring (n=73) in University Hospital Kaunas Clinics in the year 2018-2019.

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Result: The study included 181 patients, 115 women, and 66 men. In total, 108 patients

were referred for oesophageal manometry and 73 patients for 24-hour Impedance pH monitoring. Among patients referred for routine oesophageal manometry, 15 (13%) patients were referred for suspected achalasia, 80 (74%) were sent prior to the pH monitoring for localization of lower oesophageal sphincter, 10 (9%) with having non-cardiac chest pain and 3 (3%) for dysphagia associated with systemic connective tissue disorder. Amid patients referred for routine ambulatory pH monitoring the following indications were used:

gastroesophageal reflux disease refractory to PPI therapy (66 patients, 90%) and evaluation of oesophageal motility prior to anti-reflux surgery (7 patients, 10%). All of the indications used for referral were consistent with the indications recommended for these examination methods in the clinical guidelines.

Conclusions: Ambulatory oesophageal manometry is recommended for the following

indications: achalasia, dysphagia, non – cardiac chest pain, prior to elective anti-reflux surgery, and before pH monitoring for the location of LOS. Main indications for the 24-hour Impedance pH monitoring include PPI refractory GERD, non – erosive RD, and prior to elective anti-reflux surgery.

The study assessed that in 2018 – 2019 in University Hospital Kaunas Clinics four indications were used to refer patients for oesophageal manometry, that is suspected achalasia, before pH monitoring, non – cardiac chest pain, and dysphagia associated with systemic connective tissue disorders. Indications used for referral for 24-hour Impedance pH monitoring included PPI refractory GERD and prior to elective anti-reflux surgery.

The study concluded that all of the indications used for referral for both oesophageal manometry and Impedance pH monitoring tests in University Hospital Kaunas Clinics in 2018-2019 were consistent with the indications recommended for these examination methods in the clinical guidelines.

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ACKNOWLEDGEMENT

I would like to thank my supervisor Dr. Jaune Ieva Lukosiene for her support, guidance and patience throughout this final master thesis. She has been of immense help in the time of need to be able to reach the aim of this work.

CONFLICT OF INTEREST

The authors report no conflict of interest.

ETHICS COMMITTEE APPROVAL

Evaluation of Indications of Patients referred to Ambulatory Oesophageal Manometry & 24-hour Impedance pH monitoring in University Hospital Kaunas Clinics in 2018-2019.

The final master‘s thesis was completed after obtaining the permit from the Bioethics Center of the Lithuanian University of Health Sciences Nr. BEC-MF-396.

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ABBREVIATIONS LIST

● HRM – high‐resolution manometry ● LOS – lower oesophageal sphincter ● EGJ – esophagogastric junction

● GERD – gastroesophageal reflux disease ● NERD – non erosive reflux disease ● PPI – proton pump inhibitors

TERMS

ICD-10 Classification:

● K21 – GERD

● K22 – Other diseases of oesophagus - K22.0 – Achalasia of cardia

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INTRODUCTION

Oesophageal manometry was first introduced in 1883. Today, high‐resolution manometry (HRM) is the primary method used to evaluate oesophageal motor function, incorporating up to 36 pressure sensors, spaced 1 cm apart along a catheter. HRM with pressure topography has improved our ability to study oesophageal motility and visualize both peristaltic and sphincter functions [1].

Ambulatory oesophageal pH monitoring is an essential method in patients exhibiting signs of non-erosive reflux disease (NERD) to make an objective diagnosis [2]. In recent years, major changes in oesophageal functional testing have occurred: first, the introduction of reflux detection with impedance monitoring in addition to pH recording, allowing better

discrimination of hypersensitive oesophagus from functional heartburn or functional chest pain; second the introduction HRM, and third novel definitions of hypertensive motility disorders [3].

The most accurate methods for diagnosing GERD are conventional pH monitoring and impedance testing. The latter is capable of detecting reflux episodes, regardless of their nature, whereas conventional pH-metering identifies acid refluxes, presenting, in prospective studies for cough investigation, 90% sensitivity and specificity between 66% and 100% [4].

Oesophageal 24-hour pH-metry with or without combined impedance is usually performed in patients with negative endoscopy and reflux symptoms who have a poor response to anti-reflux medical therapy to assess oesophageal acid exposure and symptom-anti-reflux correlations [5].

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AIMS AND OBJECTIVES

Aim:

To analyse indications used for referring patients for ambulatory Oesophageal Manometry & 24-hour Impedance pH monitoring in University Hospital Kaunas Clinics in 2018-2019 and to compare them to the indications recommended by the clinical guidelines.

Objectives:

● To review the existing literature in the field of functional gastrointestinal testing and to comprehend clinical scenarios in which these methods are adaptable.

● To evaluate clinical cases in which patients were referred for oesophageal manometry and 24-hour Impedance pH monitoring in University Hospital Kaunas Clinics in 2018-2019.

● To compare the indications used for referral for oesophageal manometry and 24-hour Impedance pH monitoring in University Hospital Kaunas Clinics in 2018-2019 to indications recommended by the guidelines.

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LITERATURE REVIEW

OESOPHAGEAL MANOMETRY

Oesophageal manometry is a procedure which measures the strength and function of the muscles in patient’s oesophagus [6].

Instructions before the procedure

The patient is advised not to eat or drink 3 hours prior to the test. The patient must discontinue all prokinetic medications (Prepulsid, Domperidone, Metaclopramide) 7 days prior to testing [8].

Protocol for performing the procedure

Before the procedure begins, a topical anaesthetic is applied in patient’s nose. Then a tube is inserted through the patient’s nose and oesophagus, moving on into his/hers stomach, and then it is slowly withdrawn. The measurements are taken of the contractions and relaxation of the muscles (sphincters) at the start and end of the patient’s oesophagus, as well as the squeezing (peristalsis) that pushes the food down into stomach. The procedure usually takes around 1-1½ hours [7].

Indications for the procedure

● Non – cardiac chest pain / symptoms not diagnosed by endoscopy ● Achalasia / another type non – obstructive dysphagia (spasm)

● Pre – operation constructive surgery for GERD (Scleroderma/ Achalasia) ● Post – operation dysphagia (surgical treatment for reflux or after treatment for

achalasia)

● Prior pH monitoring for location of LOS (electrode positioning) ● Oesophageal motility associated with systemic diseases [9] [10]

Achalasia

Achalasia is a motility disease of the oesophagus that presents with signs and symptoms of dysphagia, regurgitation of undigested meals, breathing signs and symptoms (nocturnal cough, recurrent aspiration, and pneumonia), chest pain, and weight loss. Spasm or failure to relax the lower oesophageal sphincter (LOS) is a pathophysiological basis of achalasia, ensuing in an impaired glide of ingested meals into the stomach. Achalasia consequences from the disappearance of the myenteric neurons that coordinate oesophageal

peristalsis and LOS relaxation [14].

The analysis of achalasia is showed with HRM, that is the present gold standard test. Achalasia is now diagnosed to be present with 3 distinct manometric subtypes - All 3

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subtypes have impaired esophagogastric junction (EGJ) relaxation, however the distinguishing functions are the pattern of oesophageal pressurization and contraction. Achalasia type I (2nd most common; 20%–40% of cases) is characterized through 100% failed peristalsis (aperistalsis) with the absence of panesophageal pressurization to greater than 30 mm Hg, achalasia type II (most common; 50%–70% of cases) is characterized

through 100% failed peristalsis (aperistalsis) with panesophageal pressurization to more than 30 mm Hg, and achalasia type III (least common; 5% of cases) is characterized through spastic contractions due to atypical lumen obliterating contractions with or without the periods of panesophageal pressurization. [15]

Table 1: Eckardt score for symptomatic evaluation in achalasia [16] Score Weight loss (Kg) Dysphagia Retrosternal

pain

Regurgitation

0 None None None None

1 <5 Occasional Occasional Occasional

2 5-10 Daily Daily Daily

3 >10 Each meal Each meal Each meal

There are different scores to quantify the severity and frequency of symptoms. The Eckardt symptom score is the grading system most frequently used for the evaluation of symptoms, stages and efficacy of achalasia treatment (Table 1) [16].

Symptoms only, however, now no longer reliably diagnose the disease since there is an overlap of signs and symptoms with different oesophageal diseases, especially

gastroesophageal reflux disease. Furthermore, the symptom's presence or severity now no longer correlate with manometric findings, degree of oesophageal dilatation, or prognosis [16].

Dysphagia

Dysphagia is a common symptom in the general population. A good medical history is vital for distinguishing true oesophageal dysphagia from oropharyngeal dysphagia or other causes. Oesophageal dysphagia is a so-called red flag alarm symptom requiring oesophagogastroduodenoscopy. However, even after investigations including

oesophagogastroduodenoscopy (with biopsy), barium swallow, and oesophageal manometry, no obstructive cause may be found. [19]

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Oesophageal function testing should be used for differential diagnosis of dysphagia. Dysphagia can be the consequence of hypermotility or hypomotility of the muscles of the oesophagus. Decreased esophageal or esophagogastric junction distensibility can provoke dysphagia. Oesophageal dysphagia may have structural/obstructive causes, secondary to motility disorders, or may be predominantly sensory. In a patient presenting with dysphagia, the priority is to exclude a structural cause such as an oesophageal malignancy.There are other rare causes of structural esophageal dysphagia such as lymphocytic esophagitis, esophageal compression by cardiovascular abnormalities, or esophageal involvement of Crohn's disease, which can be considered if medical history is suggestive. Causes of dysphagia that should be excluded before oesophageal function testing – tumors

(esophageal, lung, lymphoma), vascular compression (aortic, auricular), oesophageal rings, and webs, chemical or radiation injury, peptic stricture, infectious esophagitis (herpes virus, Candida albicans), eosinophilic esophagitis. [20]

Non – cardiac chest pain

It is a common disorder, thought to arise in 3–9% of the population. It is characterized via the episodes of retrosternal chest ache which continue to be unexplained after a cardiac workup. Symptoms are usually associated with the oesophagus, via visceral hypersensitivity, peculiar cerebral ache processing, altered autonomic activity, GERD, or esophageal dysmotility, generally hypertensive, spastic, or non‐specific motility disorders. The maximum truly

recognized chance element is the presence of GERD. Upper gastrointestinal endoscopy can reveal an esophageal stricture, signs of gastroesophageal reflux, or eosinophilic esophagitis as a cause. However, functional esophageal testing, including esophageal stationary

manometry and pH‐impedance monitoring, is commonly required inside the patient workup. Since esophageal spasm might arise randomly all through the day, and might be missed during the stationary manometry recording, it isn’t always unexpected that ambulatory 24‐h manometry has proved to be more sensitive than conventional stationary manometry. [3]

During the last decade, HRM has ended up being the main device to assess oesophageal motility in those patients, and it has replaced the conventional manometry as the standard of care. HRM offers visual recognition of esophageal motor problems using esophageal

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OESOPHAGEAL PH IMPEDANCE MONITORING

Oesophageal pH Impedance monitoring is a test used to measure the amount of acid refluxing from patient’s stomach into the oesophagus [6].

Instructions before the procedure

The patient is advised not to eat or drink 3 hours prior to the test. The patient must discontinue all the anti-reflux medications (Omeprazole, Lansoprazole, Esomeprazole, Pantoprazole, Rabeprazole,Nizatidine) 7 days prior to testing [8].

Protocol for performing the procedure

A very small tube is inserted through the patient’s nose into the esophagus, and then it is taped in place. The tube is then connected to a small monitor in a carrying case, that records any reflux and symptoms the patient would have. This tube remains in the nose and

esophagus for approximately 24 hours [7].

Indications for the procedure

●

Exhibiting signs of NERD

●

Suspected to have pathological GERD after surgery

●

In negative endoscopic patient prior to planned anti – reflux repair surgery.

●

Normal endoscopic findings and GERD symptoms refractory to PPI

●

Suspected ENT manifestations after failure more than 4 weeks of PPI

●

Refractory reflux in patient with chest pain after cardiac evaluation ● GERD in adult onset non- allergic asthma [11] [12]

Gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) includes intricate signs and symptoms or mucosal harm because of retrograde motion of gastric material via an incompetent EGJ. Typical GERD signs and symptoms include heartburn and regurgitation, and scientific analysis is made primarily based totally on typical signs and symptoms, supported with the aid of using symptom reaction from empiric PPI therapy. Alarm signs and symptoms (for example, dysphagia, weight loss, anemia), atypical presentations (which include chest pain, laryngeal symptoms), or loss of response to empiric therapy prompt further evaluation with an upper endoscopy (oesophagogastroduodenoscopy). If signs and symptoms persist no matter empiric therapy, and endoscopy does not reveal evidence of GERD (oesophagitis, peptic oesophageal stricture, Barrett mucosa), oesophageal function examinations are performed, which include oesophageal manometry and ambulatory reflux monitoring. An useless EGJ barrier is consistently found in GERD, regularly mixed with morphological abnormality (hiatus

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13 hernia). By contrast, motor deficiency and unusual morphology of the EGJ barrier are readily diagnosed on HRM [17].

Non-erosive reflux disease

The definition of non-erosive reflux disease (NERD) has evolved with the recognition that abnormal acid metrics on reflux monitoring predict symptom improvement. On systemic review of treatment response to PPI therapy, and abnormal pH or pH‐impedance study in the absence of oesophageal erosions is associated with a similar response to acid-suppressive therapy as with erosive esophagitis. Conditions mimicking NERD – Functional heartburn, Reflux hypersensitivity, Eosinophilic esophagitis, Achalasia spectrum disorders, Belching, and rumination [21]. The role of anti-reflux surgery in patients with NERD also scarcely has been studied. When compared with patients with ERD, patients with NERD have a lower symptom improvement rate, a higher level of dissatisfaction, and more reports of

postoperative dysphagia after anti-reflux surgery [22].

CONTRAINDICATIONS FOR OESOPHAGEAL MANOMETRY AND

PH MONITORING

The contraindications include suspected or confirmed pharyngeal or upper oesophageal obstruction, the patients who have severe coagulopathy (not anticoagulation within the therapeutic range), the patient with Bullous disorders of the oesophageal mucosa, also who have cardiac conditions in which vagal stimulation is poorly tolerated, the ones who cannot understand or follow simple instruction or have altered mental status / obtundation and the patients with peptic strictures, oesophageal ulcers, oesophageal or junctional tumours, varices or large diverticula [13].

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RESEARCH METHODOLOGY

Data analysis

The study was conducted at the University Hospital Kaunas Clinics. It included adult patients referred for routine oesophageal manometry and 24-hour Impedance pH monitoring in 2018-2019. Indications used for referral for oesophageal manometry and 24-hour Impedance pH monitoring were identified and analysed. The quantitative analysis was performed using Statistical Package for the Social Sciences (SPSS version 24.0, SPSS Inc., Chicago, IL, USA). The overall number and percentage of total sample size were reported for each indication. Indications used for referral were compared to the indications recommended by the clinical guidelines. A comprehensive literature analysis for comparison of indications was performed using search keywords (Table 2). The outcome of each individual investigation was assessed and the ratio between proven and unproven diagnosis was evaluated.

Table 2: Terms that were used in the search ● Esophageal Manometry

● 24-Hour Impedance ● pHmetry

● Drugs to stop prior tests ● Achalasia

● Non - cardiac chest pain ● GERD ● Dysphagia ● NERD ● Motility disorders ● Regurgitation ● Chest pain ● Esophagogastric junction ● High‐resolution manometry ● Heartburn ● Endoscopy

● Esophageal function tests ● Anti-reflux surgery

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RESULTS

The study included 181 patients, 115 women, and 66 men (Table 3). In total, 108 patients were referred for oesophageal manometry and 73 patients for 24-hour Impedance pH

monitoring (Table 4). In 2018, 49 patients were referred for oesophageal manometry and 32 patients were referred for 24-hour pHmetry (Table 4). In 2019, for oesophageal manometry there were 59 patients whereas for 24-hour pHmetry were referred 41 patients (Table 4).

Table 3: Number of patients according to gender

Patients in year 2018 2019

Males Females Males Females

Esophageal manometry 20 29 21 38 24-Hour impedance pHmetry 11 21 14 27

Table 4: Number of patients tested according to the year

Patients in year Esophageal manometry 24-Hour impedance pHmetry

2018 49 patients 32 patients

2019 59 patients 41 patients

Among patients referred for routine oesophageal manometry, 15 (14%) patients were referred for suspected achalasia, 80 (74%) were sent prior to the pH monitoring for

localization of lower oesophageal sphincter, 10 (9%) with having non-cardiac chest pain and 3 (3%) for dysphagia associated with systemic connective tissue disorder (Table 5).

Table 5: Total no. of patients referred for oesophageal manometry in the year 2018-19

No. Indications Number and

percentage of cases

1 Achalasia 15 patients

(14%) 2 Prior to pH monitoring 80 patients

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3 Non-cardiac pain 10 patients

(9%) 4 Dysphagia due to systemic

connective tissue disorder

3 patients (3%)

From the number of patients tested for suspected achalasia, achalasia was manometricaly proven in 10 cases whereas remaining 5 were found to be normal. All patients referred for oesophageal manometry prior to the pH monitoring for location of LOS were confirmed having no underlying motility disorders. 10 patients had non-cardiac chest pain from which 8 patients had shown no changes and no motility disorder, whereas the remaining 2 had been confirmed with a significant oesophageal motility disorder. 3 patients clinically manifested with symptoms of dysphagia which were associated with an underlying systemic connective tissue disorders. All 3 patients were confirmed of having minor motility disorder of

oesophageal peristalsis.

In summary, all of the patients referred for ambulatory oesophageal manometry corresponded with the criteria recommended by the clinical guidelines.

Table 6: Total no. of patients referred for 24-hour ph monitoring in the year 2018-19

No. Indications No. of cases

1 Normal endoscopic findings and GERD symptoms refractory to PPI

66 patients (90%)

2 Prior to planned anti-reflux repair surgery 7 patients (10%)

In the year 2018-19, a total of 73 patients were referred for 24-hour impedance pH monitoring in the University Hospital Kaunas Clinics (Table 4).

According to the objective provided by a referring physician, two indications for the procedure were used: gastroesophageal reflux disease refractory to PPI therapy (66 patients, 90%) and evaluation of GERD prior to an anti-reflux surgery (7 patients, 10%) (Table 6).

66 out of the total 73 patients were referred for ambulatory pH monitoring because of

symptoms related to GERD refractory to the PPI therapy. Vast majority of these patients had normal endoscopic findings. After completing 24-hour pHmetry, 33 out of 66 patients were confirmed of having GERD whereas rest 33 patients were found to have a normal acid exposure time.

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17 In 2018-2019, 7 patients were referred for 24-hour pHmetry for assessment of GERD prior to anti-reflux surgery. In all 7 cases, pathological acid exposure time (>4,2%) was detected and they underwent a gastrofundoplication surgery within 6 months.

Both of the indications used for referral in Kaunas Clinics were consistent with the indications recommended for these examination methods in the clinical guidelines.

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DISCUSSION

The aim of this study was to analyse if the indications for patients referred for routine

ambulatory oesophageal manometry and impedance pH monitoring were in accordance with the guidelines required for these procedures.

In recent years, major changes in oesophageal functional testing have occurred: first, the introduction of reflux detection with impedance monitoring in addition to pH recording, allowing better discrimination of hypersensitive oesophagus from functional heartburn or functional chest pain; second the introduction HRM, and third novel definitions of

hypertensive motility disorders.

A 24-hour oesophageal monitoring can be effectively used to assess the potential

relationship between symptoms and refluxes. Oesophageal pH monitoring is routinely applied using catheter – based systems and recently without pH catheter (wireless). This method is performed in cases which do not respond to medication, where there are common GERD symptoms such as heartburn and regurgitation. If symptoms are caused by GERD,

monitoring of pH can be occasionally applied for determining therapeutic drug effectiveness against GERD, where it is effective in determining the association of times of reflux with atypical symptoms. This test is usually performed as part of procedures before performing an anti-reflux surgery.

In this study, the cases of patients who underwent the procedure for oesophageal manometry and 24-hour pHmetry from 2018 to 2019 were analysed.

In patients with a clinical suspicion of GERD, in whom no esophagitis is detected, the indication for oesophageal pH monitoring is essential and irreplaceable. 24-hour pH monitoring supplies a 90.3% sensitivity and 90% specificity to diagnose GERD. When the diagnosis of esophagitis is established endoscopically in patients with suggestive symptoms , pH monitoring could be considered unnecessary.

The goals of preoperative evaluation are to confirm the disease, find the difficulties in clinical management, related the disease to symptoms (typical or atypical) and make sure of

functional condition of the oesophagus.

The results of esophageal manometries and 24-hour pH monitoring before and after

antireflux surgery show that these methods are effective in revealing the level of functional modifications established by the corrective procedure also in helping select the surgical cases using objective data.

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CONCLUSIONS

According to literature, ambulatory oesophageal manometry is recommended for the following indications: achalasia, dysphagia, non – cardiac chest pain, prior to elective anti-reflux surgery, and before pH monitoring for the location of LES. Likewise, main indications for the 24-hour Impedance pH monitoring include PPI refractory gastroesophageal reflux disease, non – erosive reflux disease, and prior to elective anti-reflux surgery.

The study assessed that in 2018 – 2019 in University Hospital Kaunas Clinics four indications were used to refer patients for oesophageal manometry, that is suspected achalasia, before pH monitoring, non – cardiac chest pain, and dysphagia associated with systemic connective tissue disorders. Indications used for referral for 24-hour Impedance pH monitoring included PPI refractory gastroesophageal reflux disease and prior to elective anti-reflux surgery.

The study concluded that all of the indications used for referral for both oesophageal manometry and Impedance pH monitoring tests in University Hospital Kaunas Clinics in 2018-2019 were consistent with the indications recommended for these examination methods in the clinical guidelines.

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PRACTICAL RECOMMENDATIONS

There were no highlighted issues in the study that needed recommendations, hence no practical recommendations are mentioned.

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Evaluation of Indications of Patients referred to Ambulatory Oesophageal Manometry & 24-hour Impedance pH monitoring in University Hospital Kaunas Clinics in 2018-2019

Evaluation of Indications of Patients referred to Ambulatory

Oesophageal Manometry & 24-hour Impedance pH monitoring in

University Hospital Kaunas Clinics in 2018-2019

Table of Contents

ABSTRACT

Author name: Jane Velda Crasto

Title:

Aim: To analyse indications used for referring patients for ambulatory Oesophageal

Objectives:

Methodology: The study was conducted at the University Hospital Kaunas Clinics. It

Research Participants: Adult patients referred for oesophageal manometry (n=108) and

Result: The study included 181 patients, 115 women, and 66 men. In total, 108 patients

Conclusions: Ambulatory oesophageal manometry is recommended for the following

ACKNOWLEDGEMENT

CONFLICT OF INTEREST

ETHICS COMMITTEE APPROVAL

ABBREVIATIONS LIST

TERMS

ICD-10 Classification:

INTRODUCTION

AIMS AND OBJECTIVES

Aim:

Objectives:

LITERATURE REVIEW

OESOPHAGEAL MANOMETRY

OESOPHAGEAL PH IMPEDANCE MONITORING

●

●

●

●

●

●

CONTRAINDICATIONS FOR OESOPHAGEAL MANOMETRY AND

PH MONITORING

RESEARCH METHODOLOGY

Data analysis

RESULTS

DISCUSSION

CONCLUSIONS

PRACTICAL RECOMMENDATIONS

REFERENCES

ANNEX NO. 1