Recommendations of the Russian Gastroenterological Association on Clinical Use of High-Resolution Manometry in Diagnosis of Esophageal Disorders

Aim. Current recommendations of the Russian Gastroenterological Association on clinical use of high-resolution manometry in diagnosis of esophageal disorders are intended to assist in clinical decision making, terminology standardisation and interpretation of clinical data.

Key points. In 2018, a joint meeting of the Russian Gastroenterological Association and Russian Neurogastroenterology and Motility Group approved unified terminology and classification of esophageal motor function disorders for high-resolution manometry diagnosis.

Gastrointestinal patient complaints typically concern esophageal disorders such as dysphagia, regurgitation, heart-burn, chest pain or belching. To exclude erosive and ulcerative lesions, eosinophilic esophagitis and organic changes, esophagogastroduodenoscopy and biopsy are recommended in pre-treatment. Upon excluding mucosal lesions and esophageal lumen obstruction as causal for symptoms, use of high-resolution manometry is recommended. This method of esophageal examination has become the “gold standard” in diagnosis of motor disorders.

High-resolution manometry enables detailed investigation of integral quantitative and qualitative characteristics of esophagus motor function and specific related disorders, analysis of esophageal contractile propagation and strictly coordinated synchronous peristalsis of upper esophageal sphincter, esophagus and lower esophageal sphincter, which malfunction may provoke development of achalasia, esophagospasm, hiatal hernia, ineffective eso pha geal motility and other motor disorders.

Conclusion. High-resolution manometry is a relatively new method for study of esophagus motor function gaining increasingly wide application in clinical practice. It enables a medical professional to obtain evidence that may critically affect the choice of optimal patient care strategy and effective treatment. Current recommendations are based on an extensive review of up-to-date information and will be updated with new corpus of clinical data and assessment emerging in evidential medicine to provide gastroenterologists country-wide with latest scientific and practical guidelines.

1. Savarino E., de Bortoli N., Bellini M., Galeazzi F., Ribolsi M., Salvador R., et al. Practice guidelines on the use of esophageal manometry — A GISMAD-SIGE-AIGO medical position statement. Dig Liver Dis. 2016;48(10):1124–35. DOI: 10.1016/j.dld.2016.06.021

2. Fox M.R., Kahrilas P.J., Roman S., Gyawali C.P., Scott S.M., Rao S.S., et al. Clinical measurement of GI motility and function: who, when and which test? Nat Rev Gastro Hepatol. 2018;15(9):568–79. DOI: 10.1038/s41575-018-0030-9

3. Trudgill N.J., Sifrim D., Sweis R., Fullard M., Basu K., McCord M., et al. British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring. Gut. 2019;68(10):1731–50. DOI: 10.1136/gutjnl-2018-318115

4. Pandolfino J.E., Kahrilas P.J. American Gastroenterological Association. American Gastroenterological Association medical position statement: Clinical use of esophageal manometry. Gastroenterology. 2005;128(1):207–8. DOI: 10.1053/j.gastro.2004.11.007

5. Clouse R.E., Staiano A., Alrakawi A., Haroian L. Application of topographical methods to clinical esophageal manometry. Am J Gastroenterol. 2000;95(10):2720–30. DOI: 10.1111/j.1572-0241.2000.03178.x

6. Pandolfino J.E., Fox M.R., Bredenoord A.J., Kahrilas P.J. High-resolution manometry in clinical practice: utilizing pressure topography to classify oesophageal motility abnormalities. Neurogastroenterol Motil. 2009;21(8):796–806. DOI: 10.1111/j.1365-2982.2009.01311.x

7. Bredenoord A.J., Fox M., Kahrilas P.J., Pandolfino J.E., Schwizer W., Smout A.J. International High Resolution Manometry Working Group. Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography. Neurogastroenterol Motil. 2012;24(1):57–65. DOI: 10.1111/j.1365-2982.2011.01834.x

8. Kahrilas P.J., Bredenoord A.J., Fox M., Gyawali C.P., Roman S., Smout A.J.P.M., Pandolfinoet J.E. The Chicago Classification of Esophageal Motility Disorders. Neurogastroenterol Motil. Dig Liver Dis. 2015;27(2):160–74. DOI: 10.1111/nmo.12477

9. Ivashkin V.T., Maev I.V., Trukhmanov A.S., Storonova O.A., Kucheryavy Yu.A., Barkalova E.V. et al. High resolution manometry and a new classification of esophageal motility disorders. Therapeutic Archive. 2018;90(5):93–100. (In Russ.). DOI: 10.26442/terarkh201890593-100

10. Ivashkin V.T., Mayev I.V., Trukhmanov A.S., Lapina T.L., Sheptulin A.A., Storonova O.A., Andreyev D.N. Diagnostics and treatment of dysphagia: clinical guidelines of the Russian gastroenterological association. Rus J Gastroenterol Hepatol Coloproctol. 2015;25(5):84–93 (In Russ.).

11. Carlson D.A., Pandolfino J.E. High Resolution Manometry and Esophageal Pressure Topography: Filling the Gaps of Convention Manometry. Gastroenterol Clin North Am. 2013;42(1):1–15. DOI: 10.1016/j.gtc.2012.11.001

12. van Hoeij F.B., Bredenoord A.J. Clinical Application of Esophageal High-resolution Manometry in the Diagnosis of Esophageal Motility Disorders. J Neurogastroenterol Motil. 2016;22(1):6–13. DOI: 10.5056/jnm15177

13. Roman S., Huot L., Zerbib F., Varannes S.B., Gourcerol G., Coffin B., et al. HRM improves the diagnosis of esophageal motility disorders in patients with dysphagia: a randomized multicenter study. Am J Gastroenterol. 2016;111(3):372–80. DOI: 10.1038/ajg.2016.1

14. Ivashkin V.T., Trukhmanov A.S. Evolution of concept of esophageal motor disturbances in pathogenesis of gastroesophageal reflux disease. Rus J Gastroenterol Hepatol Coloproctol. 2010;20(2):13–9 (In Russ.).

15. Dent J. Pathogenesis of gastroesophageal reflux disease and novel options for its therapy. Neurogastroenterol. Motil. 2008;20(1):91–102. DOI: 10.1111/j.1365-2982.2008.01096.x

16. Evsyutina Y., Trukhmanov A., Ivashkin V., Storonova O., Godjello E. Case report of Graves’ disease manifesting with odynophagia and heartburn. World J Gastroenterol. 2015;21(48):13582–6. DOI: 10.3748/wjg.v21.i48.13582

17. Herregods T.V.K., Roman S., Kahrilas P.J., Smout A.J.P.M., Bredenoord A.J. Normative values in esophageal high-resolution manometry. Neurogastroenterol Motil. 2015;27:175–87. DOI: 10.1111/nmo.12500

18. Storonova O.A., Trukhmanov A.S., Ivashkin V.T. High-resolution manometry in clinical practice: analysis of esophageal motor function according to Chicago classification. Rus J Gastroenterol Hepatol Coloproctol. 2018;28(2):11–23 (In Russ.). DOI: 10.22416/1382-4376-2018-28-2-11-23

19. Wang Y.T., Yazaki E., Sifrim D. High-resolution manometry: oesophageal disorders not addressed by the Chicago Classification. J Neurogastroenterol Motil. 2012;18(4):365–72. DOI: 10.5056/jnm.2012.18.4.365

20. Weijenborg P.W., Savarino E., Kessing B.F., Roman S., Costantini M., Oors J.M., et al. Normal values of esophageal motility after antireflux surgery; a study using high-resolution manometry. Neurogastroenterol Motil. 2015;27(7):929–35. DOI: 10.1111/nmo.12554

21. Trukhmanov A.S., Storonova O.A., Ivashkin V.T. Clinical value of motor function of digestive system investigation: past, present and future. Rus J Gastroenterol Hepatol Coloproctol. 2013;23(5):4–14 (In Russ.).

22. Kessing B.F., Bredenoord A.J., Smout A.J. Mechanisms of gastric and supragastric belching: a study using concurrent high-resolution manometry and impedance monitoring. Neurogastroenterol Motil. 2012;24(12):e573–9. DOI: 10.1111/nmo.12024

23. Shi Z., Guo J., Clarke J., Jin H., Wang X., Zhang N., et al. Roles of High-resolution Manometry in Predicting Incomplete Bolus Transit in Patients With Dysphagia. Clin Gastroenterol. 2018;52(9):e73–e81. DOI: 10.1097/MCG.0000000000000949

24. Ang D., Hollenstein M., Misselwitz B., Knowles K., Wright J., Tucker E., et al. Rapid Drink Challenge in high-resolution manometry: an adjunctive test for detection of esophageal motility disorders. Neurogastroenterol Motil. 2017;29(1). DOI: 10.1111/nmo.12902

25. Pozdnyakov Yu.M., Volkov V.S. Chest pain. Reference for physician. М.: 2006; 266 pp. (In Russ.).

26. Aziz Q., Fass R., Gyawali C.P., Miwa H., Pandolfino J.E., Zerbib F. Functional Esophageal Disorders. Gastroenterology. 2016;15:S0016-5085(16)00178-5. DOI: 10.1053/j.gastro.2016.02.012

27. Gyawali C.P., Roman S., Bredenoord A.J., Fox M., Keller J., Pandolfino J.E., et al. Classification of esophageal motor findings in gastro-esophageal reflux disease: Conclusions from an international consensus group. Neurogastroenterol Motil. 2017;29(12). DOI: 10.1111/nmo.13104

28. Pandolfino J.E., Kim H., Ghosh S.K., Clarke J.O., Zhang Q., Kahrilas P.J. High-resolution manometry of the EGJ: an analysis of crural diaphragm function in GERD. Am J Gastroenterol. 2007;102(5):1056–63. DOI: 10.1111/j.1572-0241.2007.01138.x

29. Tolone S., Savarino E., Zaninottoet G., Gyawali C.P., Frazzoni M., Bortoli N., et al. High-resolution manometry is superior to endoscopy and radiology in assessing and grading sliding hiatal hernia: A comparison with surgical in vivo evaluation. United European Gastroenterology Journal. 2018;6(7):981–9. DOI: 10.1177/2050640618769160

30. Weijenborg P.W., van Hoeij F.B., Smout A.J., Bredenoord A.J. Accuracy of hiatal hernia detection with esophageal high-resolution manometry. Neurogastroenterol Motil. 2015;27(2):293–9. DOI: 10.1111/nmo.12507

31. van Hoeij F.B., Smout A.J., Bredenoord A.J. Characterization of idiopathic esophagogastric junction outflow obstruction. Neurogastroenterol Motil. 2015;27(9):1310–6. DOI: 10.1111/nmo.12625

32. Rohof W.O.A., Bredenoord A.J. Chicago Classification of Esophageal Motility Disorders: Lessons Learned. Curr Gastroenterol Rep. 2017;19(8):37. DOI: 10.1007/s11894-017-0576-7

33. Ivashkin V.T., Trukhmanov A.S., Godzhello E.A., Mayev I.V., Evsyutina Yu.V., Lapina T.L., Storonova O.A. Diagnostics and treatment of cardiac achalasia and cardiospasm: guidelines of the Russian gastroenterological association. Rus J Gastroenterol Hepatol Coloproctol. 2016;26(4):36–54 (In Russ.).

34. Nijhuis R.A.B.O., Zaninotto G., Roman S., Boeckxstaens G.E., Fockens P., Langendam M.W., et al. European guidelines on achalasia: United European Gastroenterology and European Society of Neurogastroenterology and Motility recommendations. United European Gastroenterol J. 2020;8(1):13–33. DOI: 10.1177/2050640620903213

35. Ivashkin V.T., Trukhmanov A.S., Mayev I.V. Physiological bases for motor and evacuatory function of the gut. Rus J Gastroenterol Hepatol Coloproctol. 2007;17(5):4–10. (In Russ.).

36. Nikaki K., Sawada A., Ustaoglu A., Sifrim D. Neuronal Control of Esophageal Peristalsis and Its Role in Esophageal Disease. Curr Gastroenterol Rep. 2019;21(11):59. DOI: 10.1007/s11894-019-0728-z

37. Ivashkin V.T., Maev I.V., Trukhmanov A.S., Sheptulin A.A., Lapina T.L., Storonova O.A. Esophagospasm. Clinical reference. 2014. (In Russ.). URL: https://minzdravao.ru/sites/default/files/2015/13jezofagospazm.doc

38. Gorti H., Samo S., Shahnavaz N., Qayed E. Distal esophageal spasm: Update on diagnosis and management in the era of high-resolution manometry. World J Clin Cases. 2020;26;8(6):1026–32. DOI: 10.12998/wjcc.v8.i6.1026

39. Ivashkin V.T., Trukhmanov A.S. Hypermotor esophageal dyskinesia (esophagospasm). Esophageal disorders. Pathological physiology, symptoms, diagnosis, treatment. М.: Triad-X; 2000: 179 pp. (In Russ.).

40. Khalaf M., Chowdhary S., Elias P.S., Castell D. Distal Esophageal Spasm: A Review. Am J Med. 2018;131(9):1034–40. DOI: 10.1016/j.amjmed.2018.02.031

41. Clément M., Zhu W.J., Neshkova E., Bouin M. Jackhammer Esophagus: From Manometric Diagnosis to Clinical Presentation. Can J Gastroenterol Hepatol. 2019;3;2019:5036160. DOI: 10.1155/2019/5036160

42. Quader F., Mauro A., Savarino E., Tolone S., Bortoli N., Franchina M., et al. Jackhammer Esophagus With and Without Esophagogastric Junction Outflow Obstruction Demonstrates Altered Neural Control Resembling Type 3 Achalasia. Neurogastroenterol Motil. 2019;31(9):e13678. DOI: 10.1111/nmo.13678

43. Roman S., Pandolfino J.E., Chen J., Boris L., Luger D., Kahrilas P.J. Phenotypes and clinical context of hypercontractility in high resolution esophageal pressure topography (EPT). Am J Gastroenterol. 2012;107(1):37–45. DOI: 10.1038/ajg.2011.313

44. Gyawali C.P., Sifrim D., Carlson D.A., Hawn M., Katzka D.A., Pandolfino J.E., et al. Ineffective esophageal motility: Concepts, future directions, and conclusions from the Stanford 2018 symposium. Neurogastroenterol Motil. 2019;31(9):e13584. DOI: 10.1111/nmo13584

45. Jalil A.A.A., Castell D.O. Ineffective Esophageal Motility (IEM): the Old-New Frontier in Esophagology. Curr Gastroenterol Rep. 2016;18:1. DOI: 10.1007/s11894-015-0472-y

46. Sifrim, D., Jafari J. Deglutitive inhibition, latency between swallow and esophageal contractions and primary esophageal motor disorders. J Neurogastroenterol Motil. 2012;18:6–12. DOI: 10.5056/jnm.2012.18.1.6

47. Shaker A., Stoikes N., Drapekin J., Kushnir V., Brunt L.M., Gyawali C.P. Multiple rapid swallow responses during esophageal high-resolution manometry reflect esophageal body peristaltic reserve. Am J Gastroenterol. 2013;108:1706–12. DOI: 10.1038/ajg.2013.289

48. Min Y.W., Shin I., Son H.J., Rhee P.-L. Multiple Rapid Swallow Maneuver Enhances the Clinical Utility of High-Resolution Manometry in Patients Showing Ineffective Esophageal Motility. Medicine (Baltimore). 2015;94(40):e1669. DOI: 10.1097/MD.0000000000001669

49. Stoikes N., Drapekin J., Kushnir V., Shaker A., Brunt L.M., Gyawali C.P. The value of multiple rapid swallows during preoperative esophageal manometry before laparoscopic antireflux surgery. Surg Endosc. 2012;26(12):3401–7. DOI: 10.1007/s00464-012-2350-0

50. Gyawali C.P., Kahrilas P.J., Savarino E., Frank Zerbib F., Mion F., Smout A.J.P.M., et al. Modern diagnosis of GERD: the Lyon Consensus. Gut. 2018;67:1351–62. DOI: 10.1136/gutjnl-2017-314722

51. Marin I., Serra J. Patterns of esophageal pressure responses to a rapid drink challenge test in patients with esophageal motility disorders. Neurogastroenterol Motil. 2016;28(4):543–53. DOI: 10.1111/nmo.12749

52. Sweis R., Anggiansah A., Wong T., Brady G., Fox M. Assessment of esophageal dysfunction and symptoms during and after a standardized test meal: development and clinical validation of a new methodology utilizing high-resolution manometry. Neurogastroenterol Motil. 2014;26(2):215–28. DOI: 10.1111/nmo.12252

53. Ang D., Misselwitz B., Hollenstein M., Knowles K., Wright J., Tucker E., et al. Diagnostic yield of highresolution manometry with a solid test meal for clinically relevant, symptomatic oesophageal motility disorders: serial diagnostic study. Lancet Gastroenterol Hepatol. 2017;2(9):654–61. DOI: 10.1016/S2468-1253(17)30148-6

54. Hollenstein M., Thwaites P., Bütikofer S., Heinrich H., Sauter M., Ulmer I., et al. Pharyngeal Swallowing and Oesophageal Motility During a Solid Meal Test: A Prospective Study in Healthy Volunteers and Patients With Major Motility Disorders. Lancet Gastroenterol Hepatol. 2017;2(9):644–53. DOI: 10.1016/S2468-1253(17)30151-6

55. Sweis R., Anggiansah A., Wong T., Kaufman E., Obrecht S., Fox M. Normative values and inter-observer agreement for liquid and solid bolus swallows in upright and supine positions as assessed by esophageal high-resolution manometry. Neurogastroenterol Motil. 2011;23(6):509–18. DOI: 10.1111/j.1365-2982.2011.01682.x

56. Blonski W., Vela M., Hila A., Castell D.O. Normal values for manometry performed with swallows of viscous test material. Scand J Gastroenterol. 2008;43(2):155–60. DOI: 10.1080/00365520701679603

57. Reddy C.A., Patel A., Gyawali C.P. Impact of symptom burden and health-related quality of life (HRQOL) on esophageal motor disorders. Neurogastroenterol Motil. 2017;29(4). DOI: 10.1111/nmo.12970

58. Bennett M.C., Patel A., Sainani N., Wang D., Sayuk G.S., Gyawali C.P. Chronic Cough Is Associated With Long Breaks in Esophageal Peristaltic Integrity on Highresolution. Manometry Neurogastroenterol Motil. 2018;30;24(3):387–94. DOi: 10.5056/jnm17126

59. Ivashkin V.T., Mayev I.V., Trukhmanov A.S., Baranskaya Ye.K., Dronova O.B., Zayratyants O.V., et al. Diagnostics and treatment of gastroesophageal reflux disease: clinical guidelines of the Russian gastroenterological association. Russ Jl Gastroenterol Hepatol Coloproctol. 2017;27(4):75–95 (In Russ.) DOI: 10.22416/1382-4376-2017-27-4-75-95

60. Fornari F., Blondeau K., Mertens V., Tack J., Sifrim D. Nocturnal Gastroesophageal Reflux Revisited by Impedance-pH Monitoring. J Neurogastroenterol Motil. 2011;17(2):148–57. DOI: 10.5056/jnm.2011.17.2.148

61. Storonova O.A., Trukhmanov A.S., Dzhahaya N.L., Ivashkin V.T. Disorders of esophageal clearance in gastroesophageal reflux disease and option of their treatment. Rus J Gastroenterol Hepatol Coloproctol. 2012;22(2):14–21 (In Russ.).

62. Maev I.V., Barkalova E.V., Ovsepyan M.A., Andreev D.N., Kucheryavyi Y.A. Indicators of Esophageal pH-Impedance Monitoring and High-Resolution Manometry in Patients with Various Forms of Gastroesophageal Reflux Disease. Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2018;28(4):23–35 (In Russ.) DOI: 10.22416/1382-4376-2018-28-4-23-35

63. Pauwels A., Boecxstaens V., Andrews C.N., Attwood S.E., Berrisford R., Bisschops R., et al. How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery). Gut. 2019;68(11):1928–41. DOI: 10.1136/gutjnl-2019-318260

64. Smout A., Fox M. Weak and absent peristalsis. Neurogastroenterol Motil. Dig Liver Dis. 2012;24(1):40–7. DOI: 10.1111/j.1365-2982.2011.01831.x

65. Vela M.F., Vaezi M.F. Cost-assessment of alternative management strategies for achalasia. Expert Opin Pharmacother. 2003;4(11):2019–25. DOI: 10.1517/14656566.4.11.2019

66. Pandolfino J.E., Kwiatek M.A., Nealis T., Bulsiewicz W., Post J., Kahrilas P.J. Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology. 2008;135(5):1526–33. DOI: 10.1053/j.gastro.2008.07.022

67. Ponds F.A., Fockens P., Lei A., Neuhaus H., Beyna T., Kandler J., et al. Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: a randomized clinical trial. JAMA. 2019;322(2):134–44. DOI: 10.1001/jama.2019.8859

68. Werner Y.B., Hakanson B., Martinek J., Repici A., Rahden B.H.A., Bredenoord A.J.,et al. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia. N Engl J Med. 2019; 381:2219–29. DOI: 10.1056/NEJ-Moa1905380

69. Sanaka M.R., Thota P.N., Parikh M.P., Hayat U., Gupta N.M., Gabbard S., et al. Peroral Endoscopic Myotomy Leads to Higher Rates of Abnormal Esophageal Acid Exposure Than Laparoscopic Heller Myotomy in Achalasia. Surg Endosc. 2019;33(7):2284–92. DOI: 10.1007/s00464-018-6522-4

70. Repici A., Fuccio L., Maselli R., Maselli R., Mazza F., Correale L., et al. GERD after per-oral endoscopic myotomy as compared with Heller’s myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc. 2018;87(4):934–43.e18. DOI: 10.1016/j.gie.2017.10.022

71. Schlottmann F., Luckett D.J., Fine J., Shaheen N.J., Patti M.G. Laparoscopic Heller myotomy versus peroral endoscopic myotomy (POEM) for achalasia: a systematic review and meta-analysis. Ann Surg. 2018;267(3):451–60. DOI: 10.1097/SLA.0000000000002311

72. Makeeva N.P. Esophageal pathology in systemic scleroderma. Esophageal disorders. Pathological physiology, symptoms, diagnosis, treatment. Moscow: Triad-X; 2000. 179 pp. (In Russ.).

73. Drossman D.A., Hasler W.A. Rome IV—Functional GI Disorders: Disorders of Gut-Brain Interaction. Gastroenterology. 2016;150(6):1257–61. DOI: 10.1053/j.gastro.2016.03.035

74. Bredenoord A.J., Weusten B.L.A.M., Sifrim D., Timmer R., Smout A.J.P.M. Aerophagia, gastric, and supragastric belching: a study using intraluminal electrical impedance monitoring. Gut. 2004;53(11):1561–5. DOI: 10.1136/gut.2004.042945

75. Maev I.V., Kucheryaviy Y.A., Barkalova E.V., Ovsepyan M.A. A Patient with Uncontrollable Belching: What to Do? Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2018;28(6):68–76. (In Russ.). DOI: 10.22416/1382-4376-2018-28-6-68-76

76. Koukias N., Woodland P., Yazaki E., Sifrim D. Supragastric Belching: Prevalence and Association With Gastroesophageal Reflux Disease and Esophageal Hypomotility. J Neurogastroenterol Motil. 2015;21(3):398–403. DOI: 10.5056/jnm15002

77. Tack J., Talley N.J., Camilleri M., Holtmann G., Hu P., Malagelada J.-R., Stanghellini V. Functional gastroduodenal disorders. Gastroenterology. 2006;130(5):1466–79. DOI: 10.1053/j.gastro.2005.11.059

78. Clouse R.E., Richter J.E., Heading R.C., Janssens J., Wilson J.A. Functional esophageal disorders. Gut. 1999;45(2):1131–6.

79. Malcolm A., Thumshirn M.B., Camilleri M., Williams D.E. Rumination syndrome. Mayo Clin Proc. 1997;72(7):646–52. DOI: 10.1016/S0025-6196(11)63571-4

80. Rommel N., Tack J., Arts J., Caenepeel P., Bisschops R., Sifrim D. Rumination or belching-regurgitation? Differential diagnosis using oesophageal impedance-manometry. Neurogastroenterol Motil. 2010;22(4):e97–104. DOI: 10.1111/j.1365-2982.2009.01431.x

81. Kessing B.F., Bredenoord A.J., Smout A.J. Objective manometric criteria for the rumination syndrome. Am J Gastroenterol. Dig Liver Dis. 2013;109(1):52–9. DOI: 10.1038/ajg.2013.428

82. Simrén M., Silny J., Holloway R., Tack J., Janssens J., Sifrim D. Relevance of ineffective oesophageal motility during oesophageal acid clearance. Gut. 2003;52(6):784–90. DOI: 10.1136/gut.52.6.784

83. Imam H., Shay S., Ali A., Baker M. Bolus transit patterns in healthy subjects: a study using simultaneous impedance monitoring, videoesophagram, and esophageal manometry. Am J Physiol Gastrointest Liver Physiol. 2005;288(5):G1000–6. DOI: 10.1152/ajpgi.00372.2004

84. Lin Z., Yim B., Gawron A., Imam H., Kahrilas P., Pandolfino J. The four phases of esophageal bolus transit defined by high-resolution impedance manometry and fluoroscopy. Am J Physiol Gastrointest Liver Physiol. 2014;307(4):G437–44. DOI: 10.1152/ajpgi.00148.2014

85. Mainie I., Tutuian R., Patel A., Castell D. Regional esophageal dysfunction in scleroderma and achalasia using multichannel intraluminal impedance and manometry. 2008;53(1):210–6. DOI: 10.1007/s10620-007-9845-x

86. Tutuian R., Castell D. Combined multichannel intraluminal impedance and manometry clarifies esophageal function abnormalities: study in 350 patients. Am J Gastroenterol. 2004;99(6):1011–19. DOI: 10.1111/j.1572-0241.2004.30035.x

87. Tutuian R., Mainie I., Agrawal A., Gideon M., Katz P., Castell D. Symptom and function heterogenicity among patients with distal esophageal spasm: studies using combined impedance-manometry. Am J Gastroenterol. 2006;101(3):464–69. DOI: 10.1111/j.1572-0241.2006.00408.x

88. Tutuian R., Castell D. Clarification of the esophageal function defect in patients with manometric ineffective esophageal motility: studies using combined impedancemanometry. Clin Gastroenterol Hepatol. 2004;2(3):230–6. DOI: 10.1016/s1542-3565(04)00010-2