Synonym/Acronym
esophageal function study, esophageal acid study (Tuttle test), acid reflux test, Bernstein test (acid perfusion), esophageal motility study.
Rationale
To evaluate potential ineffectiveness of the esophageal muscle and structure in swallowing, vomiting, and regurgitation in diseases such as scleroderma, infection, and gastric esophageal reflux. Additional testing commonly performed in conjunction with esophageal manometry has reduced the frequency of requests for more invasive and time-consuming studies involving aspiration of gastric contents. (Note: Despite decreased use, gastric analysis and gastric acid stimulation remain the gold standard for measurement of gastric acid secretion.)
Patient Preparation
There are no activity restrictions unless by medical direction. Under medical direction, the patient should withhold medications for 24 hr before the study. Instruct the patient to fast and restrict fluids for 6 hr prior to the procedure to reduce the risk of aspiration related to nausea and vomiting. Patient may be required to be NPO after midnight. The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at https://pubs.asahq.org/anesthesiology/article/126/3/376/19733/.
Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Protocols may vary among facilities.
Normal Findings
- Acid reflux (EM study): No regurgitation (reflux) into the esophagus
- Esophageal sphincter pressure (EM study): 10 to 20 mm Hg
- Esophageal secretions: pH 5 to 6
- Acid perfusion (Bernstein test): Negative (no discomfort or pain following instillation of hydrochloric acid)
- Acid clearing (Tuttle test): Fewer than 10 swallows
(Study type: Manometric; related body system: Digestive system.)
EM includes several minimally invasive studies performed to assist in diagnosing abnormalities of esophageal muscle function and structure. EM can be conducted using either conventional or high-resolution manometry. The difference between the two procedures is that high-resolution manometry uses up to 36 pressure sensors spaced at a distance of 1 cm from each other along the catheter while conventional EM has five pressure sensors that are spaced farther apart along the catheter. Therefore, the high-resolution technology is more accurate in identifying changes in pressure and provides multiple motility tracings. High-resolution manometry is considered to be the gold standard for the diagnosis of achalasia.
Tests included in EM:
- Lower esophageal sphincter pressure (manometry)
- Motility patterns (e.g., sequence and duration) that occur during swallowing (manometry)
Tests performed in combination with EM include:
- Acid reflux (pH measurements)
- Transnasal pH probe (gold standard for esophageal pH measurements)
- Wireless pH probe-capsule allows for normal fluid and dietary activities over the desired time frame (e.g., 24 hr)
- Acid perfusion (Bernstein test) where instillation of 0.1 N HCl acid is used to reproduce symptoms of acid reflux (positive test)
- Acid clearing (Tuttle test) where after 0.1 N HCl acid is instilled into the esophagus, the patient swallows and pH is recorded until the acid is no longer detected; the number of swallows is recorded and compared to the normal value
Newer technology that captures direction and movement patterns in the esophagus as well as pH measurements
- Esophageal electrical impedance or multichannel intraluminal impedance (MII) where a catheter detects peristaltic movements in the esophagus and can identify the direction of movement of either acidic and nonacidic reflux
EM can be used to document the effects of gastric acid in the esophagus, differentiate acid reflux/gastroesophageal reflux disease (GERD) or esophagitis from cardiac-related issues, and quantify GERD. EM is indicated when a patient is experiencing difficulty swallowing (dysphgia), heartburn (pyrosis), regurgitation, or vomiting or has chest pain for which no diagnosis has been found.
The lower esophageal sphincter (LES) muscles normally prevent gastric reflux. These muscles are controlled involuntarily (i.e., controlled by the autonomic nervous system), and when LES pressure is too low, the sphincter does not close normally, which can allow gastric acid and stomach contents to flow backward from the stomach into the esophagus. Weak peristalsis indicates abnormal motility during which food and fluids are unable to pass through the esophagus into the stomach. A decrease in esophageal pH associated with acid reflux can be recorded at the same time. pH measurements can be done as a “one-time” study, or with the introduction of smaller, wireless catheters, measurements can be conducted over a 24-hr period.
Chest x-rays may also be requested in order to evaluate the esophagus for abnormal appearance, especially related to achalasia.
Patients with unstable cardiopulmonary status, blood coagulation defects, recent gastrointestinal surgery, esophageal varices, or bleeding.
Patients who are unable to be cooperative during the procedure.
Abnormal Findings Related to
- Achalasia (related to prolonged duration of increased LES pressure; usually diagnosed between ages of 26 and 60 yr)
- Chalasia (decreased LES pressure related to incompetent or relaxed LES; commonly occurs in newborns, evidenced by frequent vomiting)
- Defective LES structure
- Esophageal scleroderma (decreased LES pressure related to smooth muscle atrophy and fibrosis of the esophagus)
- Esophagitis (decreased motility and LES pressure related to effects of acid reflux on the esophagus; indicated by a positive acid perfusion/Bernstein test)
- GERD (related to decreased LES pressure)
- Hiatal hernia (related to decreased LES pressure)
- Progressive systemic sclerosis (scleroderma) (decreased LES pressure related to smooth muscle atrophy and fibrosis of the esophagus)
- Spasms
Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Review the procedure with the patient.
- Discuss how this procedure can assist in assessing the esophagus.
- Explain that the procedure takes about 30 to 45 min and is performed in an endoscopy suite.
- Explain that there will be an inability to speak during the procedure but breathing will not be affected. There may be gagging when the scope is inserted. Be sensitive to concerns about choking.
- Ensure the patient removes dentures and eyewear.
Procedural Information
- Baseline vital signs will be recorded and monitored throughout the procedure.
- The oropharynx is sprayed or swabbed with a topical local anesthetic.
- An emesis basin is available to collect the increased saliva produced if the gag reflex is impaired. Suctioning of the mouth, pharynx, and trachea is performed as necessary, and oxygen will be administered as ordered.
Esophageal Manometry
- One or more small tubes are inserted through the nose into the esophagus and stomach.
- A small transducer is attached to the ends of the tubes to measure lower esophageal sphincter pressure, intraluminal pressures, and regularity and duration of peristaltic contractions.
- The patient is instructed to swallow small amounts of water or flavored gelatin.
Esophageal Acid and Clearing (Tuttle Test)
- With the tube in place, a pH electrode probe is inserted into the esophagus.
- Valsalva maneuvers are performed to stimulate reflux of stomach contents into the esophagus.
- If acid reflux is absent, 100 mL of 0.1% hydrochloric acid is instilled into the stomach during a 3-min period, and the pH measurement is repeated.
- Decreased pH is a positive finding for gastroesophageal reflux.
- To determine acid clearing, hydrochloric acid is instilled into the esophagus and the patient is asked to swallow while the probe measures the pH.
- The number of swallows required to clear the acid determines the effectiveness of esophageal motility.
- Greater than 10 swallows is a positive result for deceased esophageal motility.
Acid Perfusion (Bernstein Test)
- A catheter is inserted through the nose into the esophagus, and the patient is asked to inform the health-care provider (HCP) when pain is experienced.
- Normal saline solution is allowed to drip into the catheter at about 10 mL/min. Then hydrochloric acid is allowed to drip into the catheter.
- Pain experienced when the hydrochloric acid is instilled indicates an esophageal abnormality.
- No pain indicates the symptoms are the result of some other condition.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
Safety Considerations
- Anticoagulants, aspirin, and other salicylates should be discontinued by medical direction for the appropriate number of days prior to a procedure in which bleeding is a potential complication.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
- Monitor the patient for complications related to the procedure.
- Potential complications related to the procedure include aspiration of stomach contents into the lungs, dyspnea, tachypnea, or adventitious sounds.
Treatment Considerations
- Follow postprocedure vital sign and assessment protocol.
- Restrict eating or drinking until the gag reflex returns and then eat lightly for 12 to 24 hr.
- Resume usual activity, medication, and diet 24 hr after the examination or as tolerated, as directed by the HCP.
- Advise to expect some throat soreness and possible hoarseness. Discuss the use of warm gargles, lozenges, or ice packs to the neck, and advise to drink cool fluids to alleviate throat discomfort.
- Emphasize that any severe pain, fever, difficulty breathing, or expectoration of blood must be immediately reported. Discuss the symptoms of low Hgb and Hct associated with anemia and blood loss.
Safety Considerations
- Observe the patient for indications of perforation: painful swallowing with neck movement, substernal pain with respiration, shoulder pain, dyspnea, abdominal or back pain, cyanosis, and fever.
Clinical Judgement
- Consider how to convey the value of this procedure in identifying the cause of anemia related to esophageal dysfunction and determining therapeutic interventions.
Follow-Up Evaluation and Desired Outcomes
- Understands treatment options for anemia, including the purpose, risks, and benefits of blood transfusion.
- Understands that other diagnostic studies may be needed to establish or confirm a diagnosis. For additional information regarding related diagnostics, refer to the studies titled “Barium Swallow,” “Chest X-Ray,” and “Upper Gastrointestinal and Small Bowel Series.”
- Recognizes the importance of reporting symptoms of anemia and blood loss to the HCP.