Diagnosing Difficult Digestive Disorders


Manometry Testing Helps Young Patients

As any parent knows, an upset stomach can ruin a child’s day or cause a sleepless night.

But for children with more serious disorders of the digestive system, the pain and medical complications can go well beyond discomfort.

For the digestive system to function properly, a complicated sequence of muscle contractions and responses takes place, from swallowing to digestion to bowel movement. If muscles or nerves involved don’t develop properly, a child can experience a variety of ailments including vomiting, acid reflux, aspiration, constipation and malnutrition.

Diagnosing these ailments sometimes requires advanced testing. In 2016, Our Lady of the Lake Children’s Hospital began performing a new kind of diagnostic test called manometry, which can identify precise trouble spots along the digestive tract. Manometry tests, performed on an outpatient basis, identify problems with movement and pressure in the digestive system.

Meredith Hitch, MD, a pediatric gastroenterologist at Our Lady of the Lake Children’s Hospital, began performing manometry testing in 2016 after she completed an apprenticeship at Children’s Healthcare of Atlanta. There, she studied under Jose Garza, MD, considered a national leader in the field of manometry.

“Sometimes we see patients whose symptoms are bad, but there seems to be no clear cause after we do lab work or scope them,” Dr. Hitch says. “Things may look normal, but the child has symptoms, and manometry helps us pinpoint a diagnosis.”

With so many advancements in care for premature births, more children grow to childhood and beyond and encounter complex digestive ailments resulting from malformations of the digestive tract. Some of those children may need manometry studies to properly diagnose the problem.

Lexi Crabtree, from Dry Prong, La., is one such child. She was born unresponsive, and it took doctors 20 minutes to revive her. Since surviving a traumatic birth, Lexi continues to face a litany of digestive disorders ranging from chronic stomach pain to repeated cases of pneumonia that are progressively worse.

Manometry studies performed this spring revealed that her swallow reflex is very weak, that liquids often collect in her upper esophagus, and that both food and liquids often back up into her lungs, likely the cause of the recurrent pneumonia.

Angela is now seeking further treatment to address the issues revealed in the manometry study. “It was no picnic, but it was worth it,” she says.

In a typical manometry test, one nostril is anesthetized with a numbing lubricant. A thin, flexible tube is passed through the anesthetized nostril, down the back of the throat, and into the esophagus as the child swallows. With further swallowing, the tube is passed down into the stomach.

The child then may be asked to swallow some juice, some pudding and some crackers. The tests create color scans resembling weather radar images which show how much pressure is applied to the tube, where, and when during swallowing.

A common condition children experience is the inability to swallow properly. This can happen because the esophagus fails to develop fully, which can especially affect babies born prematurely. In these children, the muscles often don’t contract correctly or in the normal sequence.

“Manometry allows you to see what the muscles are doing,” Dr. Hitch says. “Sometimes the muscles around a child’s esophagus don’t relax to allow food to go down. Manometry gives us more nuance, tells us if we need to do surgery or alternative treatment to relax those muscles,” Dr. Hitch says.

There are two basic types of manometry testing. One identifies problems with movement and pressure in the esophagus, which can cause problems such as heartburn or acid reflux. These tests measure the strength and muscle coordination of the esophagus when a child swallows.

The second area of manometry involves anorectal testing, which is used to diagnose problems of the bowels and lower intestines, such as constipation or incontinence. To perform these tests on babies, sedation is used, but older children need to be awake and cooperative.

“A lot of times, the behavior that gets them constipated is the same that would prevent us from getting the study,” Dr. Hitch says. “We have kids who hold their urges all the time; maybe they can’t focus on things. Some hold it in and then have accidents. Or it’s a kid that it hurts to have a bowel movement so they hold it in until they can’t and there’s incontinence from that.”

Manometry testing can distinguish whether such conditions are behavioral, resulting perhaps from social chaos in their lives, or something simple such as a transition from breast milk to solid foods in infants, or when children start school. In some cases, though, the conditions result from a lack of normal development and nerves and muscles around the intestines, colon and rectum. “Constipation is not uncommon,” Dr. Hitch says.

Not surprisingly, anorectal manometry can be challenging, especially if a child is embarrassed or ashamed of their condition. To destigmatize their conditions and normal bodily functions, Dr. Hitch and her staff take a light-hearted approach. That means plenty of humorous emojis, jokes and uninhibited conversations about going to the bathroom.

For those patients who are suitable for manometry testing, the information gained is valuable, Dr. Hitch says. “We now have new and better tools and procedures to help diagnose and treat problems of the digestive tract in children.”