How to perform high-resolution manometry: a step-by-step guide

High-resolution manometry (HRM) measures pressure and coordination throughout the oesophagus, upper oesophageal sphincter and lower oesophageal sphincter. It is used to investigate dysphagia, regurgitation, chest pain, achalasia and suspected motility disorders when endoscopy has not explained the symptoms.

The test is technically straightforward, but reliable interpretation depends on careful preparation, consistent catheter placement and an appropriate swallowing protocol. In Australia, the study may be performed in a public hospital, private gastroenterology clinic or tertiary motility service, so local equipment, referral pathways and reporting systems should be checked before starting.

Confirm the indication and prepare the patient

Review the referral, previous endoscopy, barium swallow and relevant surgical history. Ask about dysphagia to solids and liquids, food sticking, weight loss, reflux symptoms and previous fundoplication or bariatric surgery. Explain that HRM is uncomfortable but brief, and that the patient remains awake and breathing normally.

The patient should usually fast according to the laboratory’s protocol, commonly avoiding solid food for six hours and clear liquids for two hours. Confirm whether medicines that affect motility need to be withheld. Australian services should provide instructions that are practical for patients travelling from regional areas, including those coming to Melbourne, Brisbane or Perth for a specialist appointment.

Check the equipment and calibrate the catheter

Use a water-perfused or solid-state high-resolution catheter with closely spaced pressure sensors. Inspect the catheter, confirm that all channels are functioning and calibrate it according to the manufacturer’s instructions. Enter the patient’s details accurately, as errors can affect the report and create problems when studies are reviewed by a multidisciplinary team.

Explain the procedure again immediately before insertion and obtain consent. Lubricate the catheter with a water-soluble gel, avoiding excessive lubricant that could interfere with pressure transmission. A clean technique and appropriate infection-control process are essential, particularly in busy Australian outpatient units where equipment is used across several lists.

Position the patient and pass the catheter

Ask the patient to sit upright or lie in the agreed starting position. Gently pass the catheter through a nostril while the patient takes small sips of water. Advance it into the stomach, confirming that the distal sensors record gastric pressure and that the catheter spans the lower oesophageal sphincter.

If passage is difficult, pause rather than forcing the catheter. Nasal obstruction, a large hiatal hernia or previous upper gastrointestinal surgery may require repositioning or medical review. For complex cases, teams may also revisit local airway and perioperative teaching, such as this resource on difficult airway management, although routine HRM does not require anaesthesia.

Record the resting pressure profile

Allow the patient to relax and breathe quietly while recording the baseline period. Identify the upper and lower sphincters, the oesophageal body and the pressure inversion point. The tracing should show stable signals without major movement artefact before provocative swallows begin.

Ask the patient to avoid talking, swallowing unnecessarily or shifting position. Coughing and retching can distort the recording. If the patient is distressed, reassure them and wait for the trace to settle. A calm explanation in plain Australian clinical language often produces a better study than repeatedly instructing the patient to “stay perfectly still”.

Perform the standard swallow sequence

Follow the laboratory protocol and the current Chicago Classification framework. A common sequence includes ten 5 mL water swallows, separated by roughly 20–30 seconds. Observe the integrated relaxation pressure, distal contractile integral, distal latency and the pattern of propagated contractions.

Additional tests, such as multiple rapid swallows, a rapid drink challenge or solid swallows, may be useful when the initial study is inconclusive or when outflow obstruction is suspected. Record the patient’s symptoms during each challenge. In a public hospital, these additions may require coordination with nursing staff and the referring gastroenterologist, while private clinics may use a fixed electronic protocol.

Assess artefacts and troubleshoot the trace

Movement, coughing, repeated swallows, catheter coiling and poor sensor contact can create misleading pressure changes. Check the raw recording rather than relying only on automated landmarks. If the catheter has migrated, ask the patient to pause and reposition it, then document the adjustment.

A technically limited study should be reported as such. Do not label achalasia, oesophagogastric junction outflow obstruction or absent contractility solely from an abnormal-looking segment. Compare the pressure pattern with symptoms, endoscopy and imaging. When seeking advice about documentation in a cross-border research or device matter, clinicians may find broader principles in this guide to international arbitration claims, although clinical reporting must follow Australian governance requirements.

Interpret, report and communicate the findings

Classify the study using the accepted diagnostic criteria and state whether the recording was technically adequate. Describe sphincter relaxation, contractile pattern, latency, pressurisation and any relevant provocative-test response. Avoid vague terms such as “abnormal motility” without explaining the physiological finding.

The report should include the indication, preparation, patient position, catheter type, swallow protocol, limitations and final interpretation. Send results through the established referral pathway, which may involve a GP, gastroenterologist, surgeon or multidisciplinary oesophageal service. Clear communication is particularly important for patients moving between Medicare-funded public care and private specialist practice.

A dependable HRM study is built from small, repeatable steps: appropriate fasting, careful calibration, confirmed gastric placement, stable baseline recording, consistent swallows and disciplined interpretation. In practical terms, use a written local checklist and do not finalise the diagnosis until the trace, symptoms and clinical history agree.