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  • Review Article
  • Published:

Clinical measurement of gastrointestinal motility and function: who, when and which test?

Nature Reviews Gastroenterology & Hepatology volume 15, pages 568–579 (2018)Cite this article

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Abstract

Symptoms related to abnormal gastrointestinal motility and function are common. Oropharyngeal and oesophageal dysphagia, heartburn, bloating, abdominal pain and alterations in bowel habits are among the most frequent reasons for seeking medical attention from internists or general practitioners and are also common reasons for referral to gastroenterologists and colorectal surgeons. However, the nonspecific nature of gastrointestinal symptoms, the absence of a definitive diagnosis on routine investigations (such as endoscopy, radiology or blood tests) and the lack of specific treatments make disease management challenging. Advances in technology have driven progress in the understanding of many of these conditions. This Review serves as an introduction to a series of Consensus Statements on the clinical measurements of gastrointestinal motility, function and sensitivity. A structured, evidence-based approach to the initial assessment and empirical treatment of patients presenting with gastrointestinal symptoms is discussed, followed by an outline of the contribution of modern physiological measurement on the management of patients in whom the cause of symptoms has not been identified with other tests. Discussions include the indications for and utility of high-resolution manometry, ambulatory pH-impedance monitoring, gastric emptying studies, breath tests and investigations of anorectal structure and function in day-to-day practice and clinical management.

Key points

  • Symptoms have poor specificity for gastrointestinal diseases, and there is a marked overlap between ‘organic disease’ (including major motility disorders) and functional gastrointestinal disease, underlining the need for testing to guide treatment.

  • New technology has driven progress, improved our understanding of gastrointestinal physiology and revolutionized the clinical measurement of gastrointestinal motility and function from oropharynx to anorectum.

  • Adherence to validated methodology is essential for the assessment of gastrointestinal motility and function to provide meaningful results.

  • Diagnoses based on valid, objective metrics (for example, Chicago Classification for oesophageal motility disorders, gastric emptying retention time and colonic transit times) are replacing subjective assessments from physiological studies.

  • High-resolution manometry has improved the inter-observer agreement and accuracy of diagnoses in patients with disorders of oesophageal and anorectal motility and function.

  • The importance of abnormal visceral sensitivity has been demonstrated in patients with functional gastrointestinal diseases.

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Fig. 1: Gastrointestinal symptoms of functional gastrointestinal disease.
Fig. 2
Fig. 3: Example of oesophageal high-resolution manometry with impedance.
Fig. 4: Example high-resolution anorectal manometry and endoanal ultrasonography in health and faecal incontinence.

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Acknowledgements

The International Working Group for Disorders of Gastrointestinal Motility and Function initiated the consensus meetings and provided material support for the consensus process. Five separate groups reviewed the current state of the art in clinical measurement of gastrointestinal motility and function: oropharynx, oesophagus, reflux disease, stomach and/or intestine and anorectum. This process was endorsed by the European Society of Neurogastroenterology and Motility (ESNM) and the European Society of Colo-Proctology (ESCP) with representation and support from the American Neurogastroenterology and Motility Society (ANMS), South and Latin American Neurogastroenterology and Motility Society (SLNG), Asian Neurogastroenterology and Motility Association (ANMA) and members of the Australasian Neurogastroenterology and Motility Association (ANGMA). Financial support was provided by the United European Gastroenterology (UEG) Education Committee, registration fees for meetings and sponsorship from all major manufacturers of physiological measurement equipment.

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Authors and Affiliations

  1. Abdominal Center: Gastroenterology, St. Claraspital, Basel, Switzerland

    Mark R. Fox

  2. Clinic for Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland

    Mark R. Fox

  3. Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    Peter J. Kahrilas

  4. Digestive Physiology, Hospices Civils de Lyon, and Lyon I University, and INSERM U1032, LabTAU, Lyon, France

    Sabine Roman

  5. Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA

    C. Prakash Gyawali

  6. Wingate Institute of Neurogastroenterology and GI Physiology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK

    S. Mark Scott

  7. Division of Gastroenterology and Hepatology, Augusta University, Augusta, Georgia, GA, USA

    Satish S. Rao

  8. Department of Internal Medicine, Israelitic Hospital, Academic Hospital of the University of Hamburg, Hamburg, Germany

    Jutta Keller

  9. Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA

    Michael Camilleri

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Contributions

All authors researched data for the article, made substantial contributions to discussion of content and reviewed or edited the manuscript before submission. M.R.F. wrote the article.

Corresponding author

Correspondence to Mark R. Fox.

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Competing interests

M.R.F. has received funding of research and/or support of educational projects from Astra Zeneca, Given Imaging/Medtronic, Mui Scientific, Nestlé, Reckitt Benckiser, and Sandhill Scientific Instruments and Medical Measurement Systems. S.R. has served as a consultant for Medtronic. She received research support from Crospon and Sandhill Scientific. C.P.G. has served as a consultant and speaker for Medtronic and has also received research funding from Medtronic. He has served as a consultant for Ironwood, Quintiles and Torax and as a speaker for Allergan. S.M.S. has received honoraria from Medical Measurement Systems/Laborie for providing training webinars and organizing teaching courses. He has also received research funding from Mui Scientific and Nestec. S.S.R. has served on advisory boards for Forest Laboratories, Intone, Synergy and Vibrant and has received research grants from Forest Laboratories, Intone, Medtronic and Synergy. J.K. has received funds for research from Given Imaging/Medtronic and Standard Instruments. She has acted as a paid consultant and/or has been paid for speaking by Abbott, Allergan, AstraZeneca, Falk Foundation, Mundipharma, Nordmark, Shire and Sucampo. M.C. has received honoraria from Biokier and Kallyope, research support from Astra Zeneca, NGM Pharma and Rhythm Pharmaceuticals, and medication supplies for clinical trials from NovoNordisk. P.J.K. declares no competing interests.

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Glossary

Dysphagia

Difficulty or discomfort in swallowing as a symptom of disease.

Achalasia

A condition in which the lower oesophageal sphincter muscle fails to relax, preventing food from passing from the oesophagus into the stomach.

High-resolution manometry

(HRM). A diagnostic system that measures intraluminal pressure activity from the throat to the stomach using a series of closely spaced pressure sensors.

Visceral sensitivity

A term used to describe the intensity of sensation (for example, fullness or pain) induced by stimulation applied to the abdominal organs (viscera). Hyposensitivity indicates that stimulation induces less intense sensation than normal; hypersensitivity, indicates that stimulation induces more intense sensation than normal.

Intraluminal impedance

A catheter-based method to detect the presence of food, fluid or gas within the lumen of the oesophagus. Measuring impedance at multiple sites (multichannel) allows for determination of the direction of movement of oesophageal contents. Combined with pH measurement, this technique is considered the gold standard for detection of acid and non-acid reflux events.

Oesophagogastric junction

(EGJ). A complex valve composed of an intrinsic, smooth muscle element (lower oesophageal sphincter and gastric cardia) and an extrinsic, striated muscle element (diaphragm).

Supragastric belching

A condition, thought to be a learned habit, in which air is repetitively sucked into the oesophagus and then immediately expelled (belched).

Contraction reserve

A term used to describe the increase in oesophageal contractility seen in response to physiological challenge (for example, multiple rapid swallows or reflux).

Aerophagia

A condition, thought to be a learned habit, in which excessive air swallowing leads to gastric distension and abdominal bloating.

Gastrointestinal scintigraphy

A test in which a radiolabelled substance (for example, an ‘eggbeater’ meal) is ingested to provide a non-invasive and quantitative measure of gastric emptying and/or orocaecal transit.

Gastric accommodation

A term used to describe the relaxation of the stomach (reduction in gastric tone and increase in compliance) that follows ingestion of a meal.

Defecography

A test in which a series of images are taken as a patient goes through the process of having a bowel movement to assess for the presence of any structural or functional pathology.

Biofeedback therapy

A specialist form of physiotherapy used to treat constipation and faecal incontinence in which sensors record muscle activity (for example, of the abdominal wall and anal sphincter) and give feedback to the patient to improve technique.

Rectocele

A herniation (bulge) of the front (anterior) wall of the rectum into the back (posterior) wall of the vagina. It occurs when the fibrous tissue between the rectum and the vagina (rectovaginal septum) becomes thin and weak over time.

Intussusception

A process in which a segment of intestine, in this case rectum, telescopes (invaginates) into the lower rectum or anal canal, causing structural outlet obstruction and difficulty with defecation.

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Fox, M.R., Kahrilas, P.J., Roman, S. et al. Clinical measurement of gastrointestinal motility and function: who, when and which test?. Nat Rev Gastroenterol Hepatol 15, 568–579 (2018). https://doi.org/10.1038/s41575-018-0030-9

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