Presenting symptoms | Criteria prior to physiology | Physiology test | Interim approach pending physiology test |
Suspected primary dysmotility (eg, suspected achalasia) | Endoscopy and biopsies | HRM | Liquid/soft, fortified diet |
Symptom recurrence following treatment of a known major motor disorder (eg, symptoms post achalasia therapy) | Endoscopy (since last therapy or recently) | HRM | Liquid/soft, fortified diet Optimise acid-reducing/antacid medication if required |
Suspected dysmotility in patients with known systemic disease (eg, severe dysphagia in known scleroderma) | Endoscopy and biopsies | HRM±24 hours pH/impedance study (pH/impedance study if reflux-like symptoms and HRM unremarkable) | Liquid/soft, fortified diet Optimise acid-reducing/antacid medication if required |
Combined reflux with (moderate/intermittent) dysphagia | Endoscopy and biopsies | HRM±24 hours pH/impedance study (pH/impedance study unless obstruction/other explanation on HRM) | Liquid/soft, fortified diet Optimise acid-reducing/antacid medication |
Reflux symptoms — patient is fit for/seeking antireflux surgery | Recent endoscopy Barium swallow if suspicion of large HH/postsurgery OGJ anomaly | HRM+24 hours pH/impedance study | Optimise acid-reducing/antacid medication |
Refractory confirmed reflux — patient is fit for/seeking antireflux surgery | Recent endoscopy Barium swallow if suspicion of large HH/postsurgery OGJ anomaly | HRM+24 hours pH/impedance study (on PPI/H2RA) | Optimise acid-reducing/antacid medication |
Atypical reflux symptoms | Recent endoscopy Barium swallow if suspicion of proximal oesophageal symptoms or OGJ anomaly | HRM+24 hours pH/impedance study | Optimise acid-reducing/antacid medication |
Rumination syndrome Supragastric belching Other suspected functional disorder | Recent endoscopy Barium swallow if suspicion of proximal oesophageal symptoms or OGJ anomaly | Postprandial HRM±24 hour pH/impedance study | Face-to-face (if permissible) or virtual cognitive behavioural therapy±diaphragmatic breathing teaching |
HH, hiatus hernia; H2RA, histamine H2 receptor antagonist; HRM, high-resolution oesophageal manometry; OGJ, oesophagogastric junction; PPI, proton pump inhibitor.