ESOPHAGEAL MOTILITY & REFLUX TESTING

1. High-Resolution Esophageal Manometry (HRM)

Assesses esophageal peristalsis, deglutitive upper/lower sphincter dynamics, and contractility patterns under the Chicago Classification v4.0.

• Fasting & Ingestion: Strict NPO for 6 to 8 hours prior to catheter placement.

• Dietary Guidance: Maintain usual diet up to the fast; avoid heavy or high-fat meals the night prior.

• Hold 48 to 72 Hours Prior:

  • Prokinetics: Metoclopramide (Reglan), Domperidone, Erythromycin, Prucalopride (Motegrity), Pyridostigmine (Mestinon).

  • Prescription Smooth Muscle Relaxants & Spasmolytics: Dicyclomine (Bentyl), Hyoscyamine (Levsin), Buspirone (Buspar), Nitrates, Calcium Channel Blockers.

  • OTC & Herbal Spasmolytics: Peppermint Oil (IBgard, Mintec), Iberogast.

  • Opioids: All short- and long-acting narcotics (alter lower esophageal sphincter tone and induce type III/hypercontractile patterns).

• Hold Morning of Procedure: Benzodiazepines, sedatives, and skeletal muscle relaxants (suppress deglutitive inhibition and peristaltic amplitude).

2. Ambulatory 24-Hour Catheter-Based pH-Impedance Monitoring

Quantifies acid and non-acid reflux, bolus clearance, mean nocturnal baseline impedance (MNBI), and symptom association probability (SAP) under Lyon Consensus 2.0.

• Fasting & Ingestion: Strict NPO for 4 to 6 hours prior to catheter placement. Resume normal eating, drinking, and daily activities once positioned.

• Dietary Guidance: Consume standard, uninhibited daily meals and typical personal triggers during recording to capture true reflux events.

• Hold Schedule (If Testing OFF Therapy for Baseline Diagnosis):

  • Hold 7 to 14 Days (Minimum 7 Days): Proton Pump Inhibitors (PPIs)—Omeprazole, Esomeprazole, Pantoprazole, Lansoprazole, Dexlansoprazole, Rabeprazole; Potassium-Competitive Acid Blockers (PCABs)—Vonoprazan (Voquezna).

  • Hold 48 Hours: Histamine-2 Receptor Antagonists (H2RAs)—Famotidine, Cimetidine; Promotility agents.

  • Hold 24 Hours: Antacids, Alginates & Mucosal Protectants—Sodium Alginate (Gaviscon Advance), Bismuth Subsalicylate (Pepto-Bismol), Calcium Carbonate (Tums), Apple Cider Vinegar, Aloe Vera Juice, Slippery Elm, White Rice Water.

• Note on ON-Therapy Testing: If ordered to evaluate refractory symptoms despite optimal medical therapy, continue all prescribed acid suppression without pause.

3. EGD with Bravo™ Wireless Esophageal pH Capsule Placement

Quantifies extended (48- to 96-hour) esophageal acid exposure time (AET) via an endoscopically affixed telemetry capsule.

• Fasting & Ingestion: Strict NPO from midnight prior for sedated endoscopy. No MRI imaging for 30 days post-placement.

• Dietary Guidance: Maintain an unrestricted, routine diet during recording; do not consume a reflux-protective diet.

• Hold Schedule (Diagnostic Baseline OFF Therapy):

  • Hold 7 to 14 Days: All PPIs and PCABs (Vonoprazan).

  • Hold 48 Hours: H2RAs (Famotidine, Cimetidine).

  • Hold 24 Hours: OTC Antacids, Alginates, Bismuth Subsalicylate, and home remedies (Apple Cider Vinegar, Aloe Vera, Slippery Elm).

4. Endoluminal Functional Lumen Imaging Probe (EndoFLIP™ - Esophagus & Pylorus)

Measures luminal cross-sectional area (CSA), distensibility index (DI), and compliance of the gastroesophageal junction or pylorus during sedated endoscopy.

• Fasting & Ingestion: Strict NPO from midnight prior.

• Hold 48 to 72 Hours Prior:

  • Smooth Muscle Relaxants: Nitrates, Calcium Channel Blockers, Dicyclomine, Hyoscyamine, Buspirone, Peppermint Oil (IBgard).

  • Motility Modulators & Prokinetics: Metoclopramide, Domperidone, Erythromycin, Prucalopride.

  • Opioids: All narcotic analgesics (suppress compliance and induce secondary spasm).

GASTRIC & SMALL BOWEL MOTILITY / LUMINAL TESTING

5. 4-Hour Solid-Phase Gastric Emptying Scintigraphy (GES)

Quantitative standard for gastric retention to diagnose gastroparesis or rapid transit (dumping syndrome).

• Fasting & Ingestion: Strict NPO from midnight prior. No smoking, vaping, nicotine patches, or morning caffeine.

• Metabolic Parameter: Fasting capillary blood glucose must be $<200\text{ mg/dL}$ prior to test meal ingestion. Bring morning insulin to take with the 99mTc-labeled meal.

• Hold 48 to 72 Hours Prior:

  • Upper GI Prokinetics: Metoclopramide (Reglan), Domperidone, Erythromycin, Prucalopride (Motegrity), Pyridostigmine (Mestinon).

  • Antiemetics & Antinausea Agents: Ondansetron (Zofran), Granisetron (Sancuso), Promethazine (Phenergan), Prochlorperazine (Compazine), Aprepitant (Emend), Scopolamine transdermal patches, Cyproheptadine (Periactin).

  • OTC & Herbal Nausea Relievers: Phosphorated Carbohydrate Solution (Emetrol), Sodium Citrate (Nauzene), Dimenhydrinate (Dramamine), Meclizine (Bonine), Ginger Root, Fennel, Chamomile, Lemon Balm, L-Carnitine, Co-Q10.

  • Antispasmodics & Spasmolytics: Dicyclomine (Bentyl), Hyoscyamine (Levsin), Peppermint Oil, Buspirone.

  • Antidiarrheals & Binders: Loperamide (Imodium), Diphenoxylate/Atropine (Lomotil), Eluxadoline (Viberzi), Alosetron (Lotronex), Colesevelam, Colestipol, Cholestyramine.

  • Cannabinoids & Opioids: All medical/recreational cannabis and prescription narcotics.

  • GLP-1 Receptor Agonists: Hold daily formulations (Liraglutide) 48 to 72 hours; hold weekly formulations (Semaglutide, Tirzepatide, Dulaglutide) for 1 to 2 weeks per institutional protocol to isolate intrinsic neuromuscular gastroparesis.

• Hold 48 Hours Prior (When Clinically Safe to Pause):

  • Neuromodulators: Amitriptyline, Nortriptyline, Mirtazapine, Olanzapine, Duloxetine, Venlafaxine, Gabapentin, Pregabalin, Topiramate.

6. Hydrogen & Methane Breath Testing (SIBO, IMO & Carbohydrate Malabsorption)

Measures exhaled hydrogen ($\text{H}_2$), methane ($\text{CH}_4$), and hydrogen sulfide ($\text{H}_2\text{S}$) gases generated by enteric microbial fermentation.

• Fasting & Dietary Protocol:

  • 12 to 24 Hours Prior (Strict Prep Diet): Eat only baked or boiled chicken/turkey breast or white fish; plain steamed white rice; eggs; plain water. Avoid all dairy, fruits, vegetables, garlic, onions, herbs, seasonings, butter, oils, and gluten grains.

  • Final 12 Hours Prior: Strict NPO fast (plain water only).

  • Day-of Test: No smoking, vaping, physical exertion, chewing gum, or mints. Brush teeth 2 hours prior without swallowing toothpaste.

• Hold Schedule:

  • Hold 4 Weeks (28 Days): Prescription Antibiotics (Rifaximin, Neomycin, Metronidazole); Herbal Antimicrobials (Berberine, Oregano Oil, Neem, FC Cidal, Dysbiocide, Candibactin-AR/BR, MBIOTA); Colon cleansing preparations (colonoscopy preps, barium enemas, colonics).

  • Hold 2 Weeks (14 Days): Probiotics (Visbiome, Culturelle, Florastor, Align, spore formulations).

  • Hold 7 Days: Laxatives & Secretagogues (PEG 3350, Senna, Bisacodyl, Milk of Magnesia, Magnesium Citrate, Linaclotide, Plecanatide, Lubiprostone, Tenapanor, Colchicine); Bulk Fibers & Dietary Laxatives (Psyllium, Methylcellulose, Calcium Polycarbophil, Flaxseed, Two Green Kiwifruit daily); Prokinetics (Prucalopride, Metoclopramide, Domperidone, Erythromycin, Pyridostigmine, Vibrant capsule); PPIs and PCABs.

  • Hold 24 to 48 Hours: Digestive Enzymes (Alpha-Galactosidase/Beano, Lactase/Lactaid, FODZYME, Fructaid); Carminatives (Simethicone, Iberogast, Peppermint Oil, Ginger, Chamomile); Elemental Diets (transition to standard prep diet 24 hours prior).

7. EGD with Duodenal Aspirate for SIBO and SIFO (Fungal Overgrowth)

Quantitative bacterial culture ($\ge 10^3 \text{ CFU/mL}$) and fungal isolation (Candida species) via sterile endoscopic aspiration.

• Fasting & Ingestion: Strict NPO for 8 to 12 hours prior to avoid dilution of secretions and reduce oral contamination.

• Hold Schedule:

  • Hold 4 Weeks (28 Days): Prescription antibiotics and herbal antimicrobials (Berberine, Oregano Oil, Neem, Candibactin, Dysbiocide).

  • Hold 2 to 4 Weeks: Systemic and oral antifungals (Fluconazole, Itraconazole, Nystatin, Amphotericin B).

  • Hold 2 Weeks (14 Days): Probiotics (Visbiome, Culturelle, Align, and specifically Saccharomyces boulardii/Florastor, which false-positives fungal aspirates).

  • Hold 7 to 14 Days: PPIs and PCABs (hypochlorhydria allows oral commensal colonization, producing false-positive aspirate culture counts).

  • Hold 7 Days: Motility agents and prokinetics (Prucalopride, Metoclopramide, Erythromycin).

  • Hold 24 to 48 Hours: Elemental diets, digestive enzymes, and carminatives.

8. EGD with Duodenal Biopsies for Disaccharidase Activity

Quantitative mucosal enzyme assay (lactase, sucrase, maltase, and palatinase/isomaltase) to assess congenital or acquired disaccharidase deficiency (e.g., CSID).

• Fasting & Ingestion: Strict NPO for 6 to 8 hours prior to sedated EGD.

• Dietary Guidance: Maintain normal baseline dietary carbohydrate intake for 2 to 3 weeks prior. Avoid zero-carbohydrate or extreme ketogenic/carnivore diets, which down-regulate baseline brush-border enzyme expression.

• Hold Schedule:

  • Hold 48 to 72 Hours: Exogenous enzyme supplements—Sacrosidase (Sucraid), Lactase (Lactaid), Alpha-Galactosidase (Beano), Pancrelipase (Creon, Zenpep), FODZYME, Fructaid, Starchway.

  • Hold 24 Hours: Adherent mucosal surface protectants—Sucralfate (Carafate), Bismuth Subsalicylate (Pepto-Bismol), Sodium Alginate (Gaviscon Advance), Aloe Vera, Slippery Elm.

COLONIC & PELVIC FLOOR TESTING

9. Colonic Transit Study (Sitzmarks® Radiopaque Markers)

Evaluates total and segmental transit time to distinguish normal transit, colonic inertia, and functional pelvic outlet obstruction.

• Fasting & Ingestion: Ingest Sitzmarks capsule (24 radiopaque markers) on Day 1 at a set morning time. Obtain an abdominal KUB radiograph on Day 5 (120 hours post-ingestion).

• Dietary Guidance: Maintain habitual daily fiber and fluid intake; do not fast.

• Hold Schedule (Hold Starting 3 to 5 Days BEFORE Ingestion and Continuously Throughout All 5 Days of the Study):

  • All Laxatives: PEG 3350 (Miralax), Senna, Bisacodyl, Milk of Magnesia, Magnesium Citrate, Docusate Sodium (Colace).

  • Dietary Laxatives & Supplemental Fibers: Psyllium (Metamucil), Methylcellulose (Citrucel), Calcium Polycarbophil (FiberCon), Flaxseed, Two Green Kiwifruit daily.

  • Secretagogues & Prokinetics: Linaclotide (Linzess), Plecanatide (Trulance), Lubiprostone (Amitiza), Tenapanor (Ibsrella), Prucalopride (Motegrity), Pyridostigmine (Mestinon), Vibrating Capsule (Vibrant), Colchicine.

  • Suppositories & Enemas: All bisacodyl, glycerin suppositories, and Fleet enemas.

  • Antidiarrheals & Spasmolytics: Loperamide, Lomotil, Viberzi, Lotronex, Dicyclomine, Hyoscyamine, Peppermint Oil.

10. High-Resolution Anorectal Manometry (HRAM) & Balloon Expulsion Test (BET)

Assesses resting/squeeze anal sphincter pressures, the rectoanal inhibitory reflex (RAIR), sensory thresholds, and pelvic floor coordination during evacuation under the London Classification.

• Fasting & Bowel Prep: Light liquid meal up to 2 hours prior. Clear the rectal ampulla using 1 to 2 Fleet saline enemas administered at home 2 hours before the examination.

• Hold 24 to 48 Hours Prior:

  • Laxatives & Stool Softeners: PEG 3350, Senna, Bisacodyl, Milk of Magnesia, Magnesium Citrate, Docusate Sodium.

  • Secretagogues & Prokinetics: Linaclotide, Plecanatide, Lubiprostone, Tenapanor, Prucalopride.

  • Antidiarrheals & Binders: Loperamide, Lomotil, Viberzi, Lotronex, Colesevelam, Colestipol, Cholestyramine.

• Hold Morning of Test: Centrally acting skeletal muscle relaxants (Baclofen, Flexeril), topical rectal lidocaine, or nitroglycerin ointments (artificially lower resting internal sphincter tone).

11. Dynamic Pelvic Defecography (MR or Fluoroscopic)

Visualizes dynamic pelvic organ support, rectal evacuation dynamics, internal intussusception, rectocele, enterocele, and dyssynergic pelvic floor contraction.

• Fasting & Bowel Prep: Clear liquid diet or light meal up to 2 hours prior. Administer a single Fleet saline enema 2 hours prior if required by imaging facility protocol.

• Hold 24 to 48 Hours Prior: Active osmotic or stimulant laxatives (Miralax, high-dose Senna, Magnesium Citrate) that induce loose, unformed liquid stool and risk premature contrast loss.

• Hold Morning of Test: Skeletal muscle relaxants.

12. Anorectal & Pelvic Floor Biofeedback Re-Education Sessions

Neuromuscular operant conditioning targeting paradoxical puborectalis contraction (dyssynergic defecation) and sensory threshold normalization.

• Preparation & Patient Protocol:

  • No Day-of Enemas: Do not administer Fleet enemas or suppositories immediately prior to sessions; mucosal liquid residue triggers urgency reflexes and interferes with probe contact.

  • Attire: Loose clothing to accommodate diaphragmatic breathing exercises.

• Dietary Guidance: Maintain consistent soluble fiber (25 to 35 g daily) and hydration (1.5 to 2 L daily) to target Bristol Stool Form Type 4.

• Medications to Continue vs. Hold:

  • Continue Baseline Stool Softeners: Continue scheduled osmotic laxatives (Miralax) or secretagogues (Linzess, Trulance). Retraining requires soft-formed stool to practice normal expulsion biomechanics without impaction.

  • Hold Morning of Session: Acute fast-acting stimulants (Bisacodyl, high-dose Senna, Magnesium Citrate) to prevent urgent incontinence; muscle relaxants and high-dose benzodiazepines that blunt cortical voluntary motor control.

Authoritative References

1. Rezaie, A., Buresi, M., Lembo, A., et al. (2017). Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus. The American Journal of Gastroenterology, 112(5), 775–784.

2. Pimentel, M., Saad, R. J., Long, M. D., & Rao, S. S. C. (2020). ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. The American Journal of Gastroenterology, 115(2), 165–178.

3. Rao, S. S. C., Valestin, J., Xiang, X., Hamdy, S., & Bradley, C. S. (2015). Clinical Trial: Biofeedback Therapy for Dyssynergic Defecation—Mechanisms of Action and Long-Term Efficacy. Neurogastroenterology & Motility, 27(8), 1147–1155.

4. Gyawali, C. P., Yadlapati, R., Fass, R., et al. (2024). Modern Diagnosis of GERD: The Lyon Consensus 2.0. Gut, 73(1), 153–171.

5. Camilleri, M., Kuo, B., Nguyen, L., et al. (2022). ACG Clinical Guideline: Gastroparesis. The American Journal of Gastroenterology, 117(8), 1197–1220.

6. Carrington, E. V., Heinrich, H., Knowles, C. H., et al. (2020). The International Anorectal Physiology Working Group (IAPWG) Recommendations: Standardized Testing Protocol and the London Classification for Disorders of Anorectal Function. Neurogastroenterology & Motility, 32(1), e13679.