Original articles
Esophageal manometry: Assessment of interpreter consistency

https://doi.org/10.1016/S1542-3565(04)00617-2Get rights and content

Background & Aims: Manometry is used widely in the evaluation of esophageal disorders. Our aim was to assess the intra- and interobserver reliability of esophageal manometry and identify potential causes for diagnostic variability. Methods: Seventy-two esophageal manometry tracings were selected randomly from archives. Eight interpreters randomly and blindly evaluated tracings. Interpreters were divided into 3 groups: highly experienced (N = 3), moderately experienced (N = 3), and inexperienced (N = 2). Each tracing was examined for abnormalities involving the lower-esophageal sphincter (LES) and esophageal body. Interpreters rendered a single diagnosis from a list of 7 manometric diagnoses: normal, nutcracker, hypertensive LES, hypotensive LES, diffuse esophageal spasm (DES), nonspecific/ineffective esophageal motility (IEM), and achalasia. Intra- and interobserver agreements were determined and reasons for varied diagnoses were investigated. Results: Overall intraobserver agreement was good (κ = .63, P < .0001). There was no difference (P = .9) between the highly and midexperienced interpreters (κ = .61 and .65, respectively). Interobserver agreement for the diagnosis of achalasia and normal motility was good (κ = .65 and .56, respectively). However, other manometric diagnoses yielded only fair interobserver agreement (κ = .27). DES, nonspecific/ineffective esophageal motility (IEM), and hypo- and hypertensive LES diagnoses showed the least agreement. Poor adherence to established manometric criteria, misinterpretation of intrabolus pressure, and technical inadequacy were the most common sources of inconsistency in interpretations. Conclusions: Manometric diagnoses of conditions other than normal or achalasia are variable and have poor interobserver variability. Given their uncertain clinical implications, we must either redefine them or eliminate them from practice.

Section snippets

Study design

A total of 72 esophageal manometry tracings were selected from the archives of the Center for Swallowing and Esophageal Disorders at the Cleveland Clinic Foundation between 2000 and 2003. At our institution, well over 1000 archived recordings are stored electronically by diagnosis. An equal number of recordings for each diagnosis were selected randomly and categorized as follows: normal, nutcracker esophagus, hypertensive LES, hypotensive LES, DES, IEM, and achalasia according to generally

Results

Table 2 lists patient demographics for the 7 manometric diagnoses. Overall, the mean (±SD) age of patients was 52 years (±13 y; range, 25–81 y), and 29 patients (40%) were men. Patients with a normal manometry diagnosis tended to be younger (mean age, 47 y), whereas those with nutcracker esophagus were older (mean age, 60 y) than others. The most common presenting symptoms before manometry were heartburn and regurgitation (37%), dysphagia (33%), chest pain (25%), and chronic cough (5%). The

Discussion

This study was a prospective, multi-interpreter, randomized, blinded study assessing the reliability of esophageal manometry interpretations. We found a strong intra- and interobserver agreement in diagnosing the 2 extremes in the spectrum of motility diagnoses, normal and achalasia, with a κ score of .63 and .68, respectively. However, despite the level of expertise, interpretation of other esophageal motility disorders have poor interobserver agreement, with a κ score .27 (Table 5). We found

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