The changing use of esophageal manometry in clinical practice

Clinical practice guidelines now advise against the use of esophageal manometry in the early evaluation of unexplained chest pain. We examined data from patients referred for manometric evaluation over a 10-yr period (1987-1996) to see if clinicians were changing practice patterns and whether manometric diagnoses were affected by the changes.

Principal indications for the procedure and manometric findings were extracted from a review of 1162 subjects referred to a single clinical laboratory. The tracings were analyzed using a standardized classification method and categorized according to a pathophysiology-based scheme. Referral indications and manometric diagnoses were compared for the first and second 5-yr periods of study.

Chest pain as a referral indication declined from the first to the second half of the study period (odds ratio, 0.44; p < 0.0001), whereas dysphagia and preoperative evaluations became more common (odds ratio, 1.3; p < 0.05; odds ratio, 13.7; p < 0.0001, respectively). Similarly, hypermotility disorders decreased in frequency (odds ratio, 0.63; p = 0.0001), whereas hypomotility disorders increased (odds ratio, 1.6; p < 0.01). The decrease in hypermotility disorders was solely related to a decrease in nonspecific spastic disorders, including nutcracker esophagus (odds ratio, 0.58; p < 0.0001); the proportion of diagnoses of achalasia and diffuse esophageal spasm remained stable.

These data show that practice patterns are already following current guidelines. They also reflect the disillusionment of clinicians with the poor specificity of manometry in chest pain management, the increasing popularity of antireflux surgery, yet the ongoing observation that nonspecific spastic disorders are closely associated with unexplained chest pain and may have a still-undefined pathogenetic role.