Guest guest Posted November 3, 2011 Report Share Posted November 3, 2011 I'm sure there is a good reason for that test, it measures pressure in the esphagus and the LES I think. I've had it done twice. I hate that test, but it is the one that confirms Achalasia, and because we are so rare, most doctors don't believe us when we say we can't swallow....or they don't know what to offer us. Good luck on Tuesday, it is a long haul to get these tests over with and get the fix you need to be able to eat again.  Wishing you all the best, hang in there....it took me many many years of frustration, this group saved my life.  Julee " Now from Oregon " From: puddleriver13 <puddleriver13@...> achalasia Sent: Thursday, November 3, 2011 10:05 PM Subject: Question: Manometry  Can someone tell me WHY this test is needed across the board? I understand that with some kinds of Achalasia it might be. But if your esophagus isn't contracting, or is contracting oddly, that's pretty visible on a barium swallow. Between that and the bird's beak, why *isn't* that enough to go ahead and diagnose Achalasia, and proceed? I just had the follow up doc visit from the hospitalization, and am puzzled why it was necessary to let me starve for an additional month. What's UP with these peeps? Oh, and the manometry is scheduled for Tuesday. At seven in the morning (So I have to leave here at five.) Wish me luck, whatever that means in this case. xox Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 4, 2011 Report Share Posted November 4, 2011 > Can someone tell me WHY this test is needed across the board? I understand that with some kinds of Achalasia it might be. But if your esophagus isn't contracting, or is contracting oddly, that's pretty visible on a barium swallow. Between that and the bird's beak, why *isn't* that enough to go ahead and diagnose Achalasia, and proceed? Good question. My significant other received an achalasia diagnosis based on a barium swallow test only (plus her signs and symptoms and a negative endoscopy). I asked our doctor if manometry would be beneficial. He said it would serve no purpose since the diagnosis was crystal clear. He also said it is a very unpleasant test and he would never put her through it without a strong reason. This made sense to me. By the way, this was at Boston Medical Center, which has good experience with achalasia. Our primary care doctor diagnoses a case or two a year. He diagnosed her very, very quickly, in contrast to some of the horror stories I've read here. Perhaps manometry is helpful in some situations, but at least from what I've learned, it is by no means always necessary to diagnose achalasia. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 4, 2011 Report Share Posted November 4, 2011 After looking around some more, found this: Barium studies versus manometry In various studies, it has been shown that 20% to 30% of patients with typical features of achalasia on barium studies have complete relaxation of the LES and, in some cases, normal LES resting pressures on manometry (Figure 4). 13-15 Despite the variable manometric findings, dysphagia in these individuals usually resolves after endoscopic or surgical treatment for achalasia. Thus, some patients with achalasia on barium studies may have no evidence of LES dysfunction on manometry. These observations raise questions about the role of manometry in patients with dysphagia and suspected achalasia. If barium studies reveal typical findings of achalasia, such patients can probably be treated without need for manometry, avoiding the cost, inconvenience, and discomfort of this procedure. Nevertheless, manometry may still be required for patients with clinically suspected achalasia who have equivocal or negative radiographic examinations. Therefore, in patients with typical radiographic findings of achalasia, the barium study can be used to guide treatment without need for manometry. If the radiographic findings are equivocal, however, manometry should be performed for a more certain diagnosis. 15 http://www.appliedradiology.com/Issues/2006/05/Articles/Achalasia-and-diffuse-es\ ophageal-spasm--Spectrum-of-findings-and-complementary-roles-of-barium-studies-a\ nd-manometry.aspx And Shimon, your S/O is very lucky!! Pisses me off, sometimes, how willing doctors are to let you/make you suffer to simply satisify their *curiosity* lol! ~~ > > > Can someone tell me WHY this test is needed across the board? I understand that with some kinds of Achalasia it might be. But if your esophagus isn't contracting, or is contracting oddly, that's pretty visible on a barium swallow. Between that and the bird's beak, why *isn't* that enough to go ahead and diagnose Achalasia, and proceed? > > Good question. My significant other received an achalasia diagnosis based on a barium swallow test only (plus her signs and symptoms and a negative endoscopy). I asked our doctor if manometry would be beneficial. He said it would serve no purpose since the diagnosis was crystal clear. He also said it is a very unpleasant test and he would never put her through it without a strong reason. This made sense to me. > > By the way, this was at Boston Medical Center, which has good experience with achalasia. Our primary care doctor diagnoses a case or two a year. He diagnosed her very, very quickly, in contrast to some of the horror stories I've read here. > > Perhaps manometry is helpful in some situations, but at least from what I've learned, it is by no means always necessary to diagnose achalasia. > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 4, 2011 Report Share Posted November 4, 2011 well, they couldnt even get the tube down my nose, i had to be put to sleep and waked up to have it, and i wondered the same thing , . kim bailey Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 4, 2011 Report Share Posted November 4, 2011 wrote: > > In various studies, it has been shown that 20% to 30% of patients with > typical features of achalasia on barium studies have complete > relaxation of the LES and, in some cases, normal LES resting pressures > on manometry (Figure 4). ... > That article was a few years old and probably was quoting even older studies. Things have been changing in the use of manometry and in the classification of achalasia, because of the use of newer high resolution manometry devices. In some patients with " vigorous achalasia " or esophageal compression the esophagus could shorten during a spasm. This could cause the LES to move off the sensor in the older manometry devices. When the LES moves off the sensor the sensor is then only under the pressure of the stomach which is less and makes the readings look like a relaxation. That is now known as a pseudorelaxation. For some interesting images see: http://ukpmc.ac.uk/articles/PMC3020387?figure=F5/ and http://gut.bmj.com/content/57/3/405/F13.large.jpg In the first link the pressure at the LES looks pretty normal until the contraction of the spasm but the spasm would have been missed on the older devices and instead would look like a relaxation. In the second link the the pressure at the LES is high, red, but drops to medium, yellow, not enough to be a complete relaxation, however an older device would have detected low pressure represented by the green (stomach) color. Also in that image at the right are tracings like the older manometry would give. The rust/brown colored line shows the sensor drop in pressure for the pseudorelaxation where there was no real relaxation. The article you gave the link for was by Marc S. Levine, MD. He is listed second on this one: Achalasia with Complete Relaxation of Lower Esophageal Sphincter: Radiographic-Manometric Correlation http://radiology.rsna.org/content/235/3/886.long#T1 There are barium images of LES that the manometries claimed had complete relaxations. see figures 1, 2 and 3: http://radiology.rsna.org/content/235/3/886/F1.expansion.html http://radiology.rsna.org/content/235/3/886/F2.expansion.html http://radiology.rsna.org/content/235/3/886/F3.expansion.html If those are images of complete relaxations what is holding the LES shut? If something else is holding the LES shut then why does Botox or manometry of the LES help when the pressure is already low do to relaxations? Could it be that the LES didn't actually relax and the manometry showed pseudorelaxations? Understand that a myotomy usually doesn't reduce the pressure as much as a complete relaxation or there would be too much reflux. Even so, that doesn't answer the question of why get a manometry if the barium looks like achalasia. Take a look at this article: Current clinical approach to achalasia World J Gastroenterol. 2009 August 28 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2731945/ " Manometry remains the diagnostic modality with the highest sensitivity and should be part of the diagnostic evaluation in all patients with achalasia. " Why do they say that? Because manometry is the most accurate way to diagnose achalasia and it tells you what kind of achalasia you have and with the newer classifications by high resolution manometry they can better predict which treatment option will work best for a patient and which patients will be hard to treat. Can a barium do that? Maybe in time they can learn from the high resolution manometry what to look for and then maybe they will be able to, but for now I have not seen it. notan Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 7, 2011 Report Share Posted November 7, 2011 Thanks for the work, notan. This (from one of your links) is why I question -- " Manometry revealed complete LES relaxation during swallowing with a normotensive sphincter at rest. Despite the manometric findings, this patient's dysphagia resolved after treatment for achalasia with botulinum toxin injection and Heller myotomy. " The manometry revealed that he didn't need what they actually treated him for, but which worked. So the point was? Satisfying the doctors' curiosity? Going to go ahead and do it tomorrow, but I'm NOT a happy camper here. Makes me like and trust them *less.* > > > > In various studies, it has been shown that 20% to 30% of patients with > > typical features of achalasia on barium studies have complete > > relaxation of the LES and, in some cases, normal LES resting pressures > > on manometry (Figure 4). ... > > > > That article was a few years old and probably was quoting even older > studies. Things have been changing in the use of manometry and in the > classification of achalasia, because of the use of newer high resolution > manometry devices. In some patients with " vigorous achalasia " or > esophageal compression the esophagus could shorten during a spasm. This > could cause the LES to move off the sensor in the older manometry > devices. When the LES moves off the sensor the sensor is then only under > the pressure of the stomach which is less and makes the readings look > like a relaxation. That is now known as a pseudorelaxation. > > For some interesting images see: > http://ukpmc.ac.uk/articles/PMC3020387?figure=F5/ > and > http://gut.bmj.com/content/57/3/405/F13.large.jpg > > In the first link the pressure at the LES looks pretty normal until the > contraction of the spasm but the spasm would have been missed on the > older devices and instead would look like a relaxation. In the second > link the the pressure at the LES is high, red, but drops to medium, > yellow, not enough to be a complete relaxation, however an older device > would have detected low pressure represented by the green (stomach) > color. Also in that image at the right are tracings like the older > manometry would give. The rust/brown colored line shows the sensor drop > in pressure for the pseudorelaxation where there was no real relaxation. > > The article you gave the link for was by Marc S. Levine, MD. He is > listed second on this one: > > Achalasia with Complete Relaxation of Lower Esophageal Sphincter: > Radiographic-Manometric Correlation > http://radiology.rsna.org/content/235/3/886.long#T1 > > > There are barium images of LES that the manometries claimed had complete > relaxations. > > see figures 1, 2 and 3: > http://radiology.rsna.org/content/235/3/886/F1.expansion.html > http://radiology.rsna.org/content/235/3/886/F2.expansion.html > http://radiology.rsna.org/content/235/3/886/F3.expansion.html > > If those are images of complete relaxations what is holding the LES > shut? If something else is holding the LES shut then why does Botox or > manometry of the LES help when the pressure is already low do to > relaxations? Could it be that the LES didn't actually relax and the > manometry showed pseudorelaxations? Understand that a myotomy usually > doesn't reduce the pressure as much as a complete relaxation or there > would be too much reflux. > > Even so, that doesn't answer the question of why get a manometry if the > barium looks like achalasia. > > Take a look at this article: > > Current clinical approach to achalasia > World J Gastroenterol. 2009 August 28 > http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2731945/ > " Manometry remains the diagnostic modality with the highest sensitivity > and should be part of the diagnostic evaluation in all patients with > achalasia. " > > Why do they say that? Because manometry is the most accurate way to > diagnose achalasia and it tells you what kind of achalasia you have and > with the newer classifications by high resolution manometry they can > better predict which treatment option will work best for a patient and > which patients will be hard to treat. Can a barium do that? Maybe in > time they can learn from the high resolution manometry what to look for > and then maybe they will be able to, but for now I have not seen it. > > notan > > > > > > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 7, 2011 Report Share Posted November 7, 2011 wrote: > > Thanks for the work, notan. This (from one of your links) is why I > question -- " Manometry revealed complete LES relaxation during > swallowing with a normotensive sphincter at rest. Despite the > manometric findings, this patient's dysphagia resolved after treatment > for achalasia with botulinum toxin injection and Heller myotomy. " The > manometry revealed that he didn't need what they actually treated him > for, but which worked. So the point was? Satisfying the doctors' > curiosity? > I think you missed my point. As I said in my last message about those images, " There are barium images of LES that the manometries claimed had complete relaxations. " They claimed it showed complete relaxations. The question is, and was, did they get that result (complete relaxations) because of the type of manometry they used and is it actually a psuedorelaxations (not real relaxations) which would have been detected with high resolution? And, if they aren't psuedorelaxations what is holding the LES closed? My guess would be that they were psuedorelaxation and that the images don't really show complete relaxations even though they claim too. I hope the test is not too bad for you. notan Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 7, 2011 Report Share Posted November 7, 2011 I see your point. I still just can't get over the sense that this is CYA or curiosity. Still not seeing where the manometry decides anything. And thanks for the good wishes! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 7, 2011 Report Share Posted November 7, 2011 wrote: > > I see your point. I still just can't get over the sense that this is > CYA or curiosity. Still not seeing where the manometry decides anything. > If it is just a matter of achalasia or not achalasia and you trust the radiologist to get it right then the barium is often enough. If there is a desire to know what type of achalasia it is, how that type is likely to impact the results of treatment, and be sure it is achalasia, then the manometry is good. Doctors make mistakes, radiologist make mistakes. Achalasia is not among the common things seen in radiology. On the other hand, for those doing esophageal motility studies achalasia is the most common motility disorder they see. Those doing the motility studies and looking at the results could also make mistakes but at least they should be expert at achalasia, if they are in a busy esophageal motility center. notan Quote Link to comment Share on other sites More sharing options...
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