The changing use of esophageal manometry in clinical practice

Objective: Clinical practice guidelines now advise against the use of esoph ageal manometry in the early evaluation of unexplained chest pain. We exami ned data from patients referred for manometric evaluation over a 10-yr peri od (1987-1996) to see if clinicians were changing practice patterns and whe ther manometric diagnoses were affected by the changes. Methods: Principal indications for the procedure and manometric findings were extracted from a review of 1162 subjects referred to a single clinical laboratory. The trac ings were analyzed using a standardized classification method and categoriz ed according to a pathophysiology-based scheme. Referral indications and ma nometric diagnoses were compared for the first and second 5-yr periods of s tudy. Results: 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), wher eas dysphagia and preoperative evaluations became more common (odds ratio, 1.3;p < 0.05; odds ratio, 13.7; p < 0.0001, respectively). Similarly, hyper motility disorders decreased in frequency (odds ratio, 0.63; p = 0.0001), w hereas hypomotility disorders increased (odds ratio, 1.6;p < 0.01). The dec rease in hypermotility disorders was solely related to a decrease in nonspe cific spastic disorders, including nutcracker esophagus (odds ratio, 0.58;p < 0.0001); the proportion of diagnoses of achalasia and diffuse esophageal spasm remained stable. Conclusions: These data show that practice patterns are already following current guidelines. They also reflect the disillusio nment of clinicians with the poor specificity of manometry in chest pain ma nagement, 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. (C ) 1998 by Am. Coll. of Gastroenterology.