Diagnostic approach to patients with suspected motility disorders: one size does not fit all

Dysphagia and retrosternal chest pain are considered typical manifestations of major esophageal motility disorders (mEMD). High-resolution manometry (HRM) is the gold standard for mEMD diagnosis, while endoscopy and barium swallow are ancillary tools. We aimed to investigate the frequency of mEMD among patients referred for HRM with typical compared to non-typical symptoms. We also evaluated endoscopic and barium swallow data from patients with mEMD who underwent HRM.

We retrospectively collected epidemiological, endoscopic, barium swallow, and HRM data from 302 patients. Atypical symptoms were considered to be heartburn, regurgitation, globus, oropharyngeal dysphagia, and epigastric pain.

The main referral symptoms were: esophageal dysphagia, 58.3%; chest pain, 13.7%; heartburn, 8.9%; regurgitation, 8.3%; and globus/oropharyngeal dysphagia/epigastric pain, 10.8%. A diagnosis of mEMD was more common when typical symptoms existed (69.9% vs. 15.4%, P<0.001). The majority of patients with mEMD in HRM, independently of their symptoms, had an abnormal barium study (typical: 94.8% vs. non-typical: 100%, P=0.633), while compatible endoscopic data tended to be observed more frequently among patients with typical symptoms (69.1% vs. 40%, P=0.057). An HRM diagnosis of mEMD among patients with compatible findings from either barium swallow or endoscopic examination was statistically more frequent among patients with typical symptoms (92.4% vs. 52.6%, P<0.001).

More than half of patients referred for HRM will be diagnosed with mEMD, at a higher rate when typical symptoms are reported. A lack of compatible endoscopic and barium swallow findings, in the absence of typical symptoms, makes the diagnosis of mEMD almost impossible.