Table 1

Triage hierarchy for upper gastrointestinal (GI) physiology investigations after the initial COVID-19 peak. Traffic light colour scheme denotes order of clinical priority (higher position indicating higher priority). Red: patients who must be prioritised and in whom delayed investigation could have negative clinical consequences. Amber: patients who may be considered for endoscopic or surgical intervention and thus should be prioritised for physiology based on symptom severity and available capacity. Green: patients who can be delayed until routine clinical services resume

Presenting symptomsCriteria prior to physiologyPhysiology testInterim approach pending physiology test
Suspected primary dysmotility (eg, suspected achalasia)Endoscopy and biopsiesHRMLiquid/soft, fortified diet
Symptom recurrence following treatment of a known major motor disorder (eg, symptoms post achalasia therapy)Endoscopy (since last therapy or recently)HRMLiquid/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 biopsiesHRM±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) dysphagiaEndoscopy and biopsiesHRM±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 surgeryRecent endoscopy
Barium swallow if suspicion of large HH/postsurgery OGJ anomaly
HRM+24 hours pH/impedance studyOptimise acid-reducing/antacid medication
Refractory confirmed reflux — patient is fit for/seeking antireflux surgeryRecent 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 symptomsRecent endoscopy
Barium swallow if suspicion of proximal oesophageal symptoms or OGJ anomaly
HRM+24 hours pH/impedance studyOptimise 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 studyFace-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.