Dysphagia and Reflux: Manometry versus Barium Swallow: 32

Purpose: To determine the concordance in diagnoses in patients with esophageal symptoms when studied by esophageal manometry and by barium swallow study using standard protocols. Methods: 100 consecutive patients were referred for esophageal manometry and also underwent a barium swallow study. Esophageal manometry was performed using a high resolution manometry catheter. Indication, percent of peristaltic contractions or abnormal contractions, amplitude of contractions, lower esophageal sphincter (LES) pressure, relaxation and final diagnosis were recorded. Barium studies were reviewed by a separate investigator (radiologist) for presence of reflux, peristalsis (normal or abnormal), delay in esophageal emptying of liquid or a barium pill and final diagnosis. Results: In 100 patients the indications for evaluation were chest pain (6), dysphagia (53), reflux/heartburn (22), cough (4), other (6) and both dysphagia and reflux (8). The manometric and radiographic diagnoses for dysphagia and reflux are shown in the table. Although the distribution of diagnoses is very similar by both methods (table), a good concordance was only seen for the diagnosis of achalsia (kappa=0.67; CI 0.48-0.87). Poor concordance was seen between reflux by barium study and low LES by manometry (kappa=0.31) and for dysmotility (kappa=0.27) and for normal study (kappa=0.03). In patients referred for dysphagia, 85% had abnormalities by manometry and 90% by barium swallow. Fifty-nine percent of patients with dysphagia had either achalasia or dysmotility by manometry, and 58% by barium swallow. Within the dysmotility diagnosis, nutcracker esophagus was found in 3 patients. Such a diagnosis is not possible by barium study. Additional findings noted on barium study included esophageal diverticula (n=12),webs(n=2) and intraluminal or extrinsic mass or mass effect (n=3). Conclusion: Good concordance is found between manometry and barium swallow study in the diagnosis of achalasia. A low LES does not predict reflux on barium swallow. The lack of concordance in other diagnoses in patients with esophageal symptoms may reflect differences in techniques between these studies or intermittent dysfunction. Barium studies may also reveal anatomic abnormalities that cannot be diagnosed by manometry. The combination of manometry and barium swallow studies increases the likelihood of detecting esophageal functional disorders.Table: Diagnosis in 100 patients referred for manometry and barium swallow study for esopahgeal symptoms