Concierge oesophageal physiology · London
High-resolution oesophageal manometry with reflux monitoring, the bundled workup before anti-reflux surgery.
The bundled workup for refractory reflux and pre-fundoplication planning: high-resolution oesophageal manometry (Chicago Classification 4.0) combined with 24-hour pH-impedance or Bravo wireless reflux monitoring. Confirms diagnosis and rules out achalasia before anti-reflux surgery.
Key facts
- 01
Definition
A bundled workup — high-resolution oesophageal manometry (HRM) with 24-hour pH-impedance monitoring or a Bravo wireless capsule study.
- 02
Chicago Classification 4.0
HRM is interpreted using the international Chicago Classification 4.0 diagnostic hierarchy.
- 03
Lyon Consensus criteria
Reflux monitoring is graded against the Lyon Consensus — acid exposure time, DeMeester score and symptom association.
- 04
Mandatory pre-fundoplication assessment
A standard-of-care workup before Nissen or Toupet fundoplication and LINX magnetic sphincter augmentation.
- 05
Rules out achalasia
Excludes achalasia and hypercontractile disorders that would contraindicate anti-reflux surgery.
- 06
Same-day or two-visit protocol
Delivered as a combined same-day protocol, or split over two short visits — whichever suits you.
Why patients choose us
- 01
The right hands
We route you to a consultant oesophageal physiologist and gastroenterologist — the people who scan you and the people who read it decide the answer.
- 02
Bundled in one visit
HRM and pH-impedance or Bravo are planned together, so you don’t make two separate trips to two separate clinics.
- 03
Independent, and free
We are paid by no clinic, so the recommendation is impartial and costs you nothing.
Indicative pricing
What HRM and reflux monitoring cost in London.
Indicative ranges across our partner clinics. Send the details and we quote firm figures across two or three options.
In short
A bundled HRM + pH-impedance workup in our network: £1,600–£2,400, with a structured report within a week.
| Study | Indicative range | Typical duration | Report turnaround |
|---|---|---|---|
| High-resolution oesophageal manometry (HRM) | £850–£1,200 | 45 min | 3–5 days |
| 24-hour pH-impedance monitoring | £950–£1,400 | 24 hrs | 5–7 days |
| Bravo wireless pH capsule (48–96 hrs) | £1,600–£2,400 | 48–96 hrs | 7–10 days |
| HRM + pH-impedance bundle | £1,600–£2,400 | Same-day + 24 hrs | 7 days |
| HRM + Bravo bundle (pre-fundoplication workup) | £2,200–£3,200 | Two visits | 10 days |
| Upper-GI surgical opinion (post-workup MDT) | £300–£500 | 30 min | Same visit |
Prices vary by clinic, whether Bravo endoscopic placement is required, and whether a same-visit consultant upper-GI opinion is included. We come back with a firm quote within one working day.
The problem
Anti-reflux surgery on the wrong physiology is the classic bad outcome.
The Chicago 4.0 diagnosis and Lyon verdict are the answer — and the physiologist and consultant interpreting them decide whether a wrap will help or harm. We route you to an oesophageal physiologist and consultant gastroenterologist, not a generalist.
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Refractory reflux on PPI?
We arrange the bundled HRM + reflux study and route findings to an upper-GI surgical MDT.
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Booked for LINX or fundoplication?
We complete the mandatory pre-operative physiology workup — and flag anyone who shouldn’t proceed.
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Achalasia suspected?
HRM confirms it, and we route to a POEM or Heller myotomy MDT rather than to an anti-reflux wrap.
The journey
From consultation to structured report — what happens, in order.
Same-day or two-visit protocol — the physiologist and consultant plan it around your diary, not theirs.
Phase 1 · Before your study
Consultation and PPI washout
Phase 2 · On the day
HRM + reflux catheter or Bravo
Phase 3 · After
Structured report and MDT
- 01
Before
Gastroenterology consultation
A short consultant clinic visit to confirm indication, symptoms and risk factors, and to plan the correct combination of tests.
- 02
Before
Withhold PPI for 7 days
Proton pump inhibitors are stopped one week before reflux monitoring so acid exposure is measured honestly. H2-blockers stopped 3 days before.
- 03
Before
Fast for 6 hours
No food or drink for 6 hours before HRM to keep the catheter passage comfortable and the tracing clean.
- 04
On the day
HRM with Chicago 4.0 protocol
A thin catheter is passed through the nose. Ten wet swallows plus provocative manoeuvres, interpreted against the Chicago Classification 4.0.
- 05
On the day
pH-impedance or Bravo capsule
Either a 24-hour transnasal pH-impedance catheter or a Bravo wireless capsule clipped to the oesophageal wall at endoscopy for a 48–96 hour study.
- 06
On the day
Symptom diary
You record meals, upright and supine time, and symptom episodes on a paper or app diary — the diary drives the symptom-reflux association analysis.
- 07
After
Structured report
A single structured report — Chicago 4.0 motility diagnosis, Lyon reflux verdict and a clear next-step recommendation for your gastroenterologist or upper-GI surgeon.
Typical end-to-end: 10–14 days including PPI washout. Structured report: within a week of the study.
What it shows
When bundled HRM and reflux monitoring is the right test.
The bundled workup answers two specific questions — how your oesophagus contracts, and how much reflux you actually have. These are the presentations we see most.
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Motility disorders (achalasia, jackhammer, IEM)
HRM detects achalasia type I, II or III, jackhammer oesophagus, distal oesophageal spasm and ineffective motility.
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Ineffective oesophageal motility
Quantifies failed and weak swallows — an IEM diagnosis materially changes the fundoplication wrap chosen.
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Acid exposure time (%)
The percentage of the 24-hour study with oesophageal pH below 4 — the Lyon Consensus threshold for pathological acid reflux.
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DeMeester score
A composite reflux score combining acid exposure, number of episodes and longest episode — the classic pH-monitoring metric.
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Non-acid reflux
Impedance detects weakly acidic and gaseous reflux events that a pH-only study would miss — relevant on PPI therapy.
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Symptom-reflux association
Symptom index and symptom association probability link your diary entries to individual reflux episodes.
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Coexistent hiatus hernia
Manometric identification of a hiatus hernia and lower-oesophageal-sphincter pressure — both drive surgical planning.
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Red flag: type I / III achalasia → POEM / Heller MDT
A confirmed achalasia diagnosis stops the anti-reflux pathway and routes you to a POEM or Heller myotomy MDT.
Next steps
What happens after the workup.
The Chicago 4.0 diagnosis and Lyon verdict decide the pathway. These are the treatment routes the workup opens.
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Optimise PPI therapy
Confirmed acid reflux with normal motility — dose adjustment, timing and adherence review before considering surgery.
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LINX magnetic sphincter augmentation
A ring of magnetic beads placed laparoscopically around the lower oesophageal sphincter — appropriate for selected motility patterns.
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Nissen or Toupet fundoplication
The definitive anti-reflux operation — a 360° Nissen or partial 270° Toupet wrap, chosen on the motility findings.
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POEM or Heller myotomy for achalasia
Per-oral endoscopic myotomy or laparoscopic Heller myotomy — the correct route once achalasia is confirmed.
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Neurogastro for functional heartburn
A normal reflux study with reflux-type symptoms — a neurogastroenterology pathway with visceral hypersensitivity treatments.
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Repeat testing post-surgery
HRM and pH monitoring after fundoplication or LINX to work up persistent dysphagia or recurrent reflux.
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Weight loss and lifestyle
The evidence-based first line — weight, elevation of the head of bed, and meal timing before any procedural step.
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MDT review
Combined upper-GI surgical and gastroenterology review of the full workup before any operation is offered.
Our vetted London network
A small panel of clinics, we picked them.
Partners across central, north, west and south London. Not listed publicly — introductions are made privately, once we understand your case.
Selection criteria
How we choose every clinic in our network.
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Consultant gastroenterologists and accredited oesophageal physiologists
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Chicago Classification 4.0 for HRM and Lyon Consensus criteria for reflux
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Same structured report used by London upper-GI surgical MDTs
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Onward LINX, fundoplication, POEM or Heller pathway if intervention is indicated
Clinical red flags
When the bundled workup is the right next test.
Nine presentations where HRM plus reflux monitoring is the physiology-defining step — not a repeat gastroscopy, not another PPI trial.
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Achalasia
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Refractory reflux
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Barrett’s with dysplasia
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Scleroderma oesophagus
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Post-fundoplication dysphagia
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Post-bariatric reflux
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Persistent dysphagia
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Alarm features (weight loss, bleeding, anaemia)
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Extra-oesophageal reflux with pulmonary sequelae
Safety and eligibility
Very safe — with practical points that matter.
HRM and reflux monitoring are low-risk. The practical points are the PPI washout, when a gastroscopy comes first, and where the study’s limits are.
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Local anaesthetic to the nose
A little numbing spray is used before the catheter is passed — most people find it uncomfortable rather than painful.
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You can breathe and speak
The catheter is thin. You can breathe normally through mouth and nose and speak throughout the test.
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PPI washout is important
Stopping PPIs 7 days before reflux monitoring is the single biggest determinant of an interpretable study — do not skip it unless your consultant tells you to.
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Bravo capsule is dislodgeable
The wireless capsule usually detaches within a week. Rare early dislodgement or chest discomfort — endoscopic removal is very seldom needed.
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Achalasia is a medical diagnosis
Confirmed achalasia is not treated with anti-reflux surgery — it requires POEM, Heller myotomy or pneumatic dilatation via an MDT.
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Alarm features first
Weight loss, iron-deficiency anaemia, gastrointestinal bleeding or progressive dysphagia require gastroscopy before physiology.
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A normal study is informative
A normal HRM and normal reflux study with typical symptoms is functional heartburn — a different treatment pathway, not a failed test.
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Cardiac chest pain first
Chest-pain-predominant reflux presentations need cardiac work-up ruled out before oesophageal physiology.
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Bring prior endoscopy and imaging
Previous OGD reports, biopsies, barium studies and CT scans materially sharpen the interpretation.
Reading your report
A physiology report can look intimidating. It isn’t.
Whatever the finding, the structured report keeps to the same four parts.
A quiet reminder
The report is written for your surgeon or gastroenterologist, not for you — and that’s normal.
If you would like us to talk you through it before your follow-up, just ask.
- 01 Header
Indication and drug washout
Your details, the reason for the workup, and confirmation of the PPI and H2-blocker washout period.
- 02 Manometry
Chicago 4.0 motility diagnosis
Integrated relaxation pressure, distal contractile integral, peristaltic pattern and the formal Chicago 4.0 diagnosis.
- 03 Reflux
Acid exposure, DeMeester and symptom association
Acid exposure time, DeMeester score, number of reflux episodes and the symptom-reflux association indices.
- 04 Impression
The conclusion: read this first
Lyon verdict, Chicago 4.0 diagnosis and the concrete next step — anti-reflux surgery, POEM, neurogastro or optimised medical therapy.
Sources
What informs this guide.
- British Society of Gastroenterology. Guidelines on oesophageal manometry and reflux monitoring.
- Yadlapati R et al. Chicago Classification of oesophageal motility disorders, v4.0.
- Gyawali CP et al. Modern diagnosis of GERD: the Lyon Consensus.
- SAGES / EAES. Guidelines for surgical treatment of gastro-oesophageal reflux disease.
Last reviewed 2026-07-30. Next review due 2027-07-30.
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Frequently asked
Everything we get asked about HRM and reflux monitoring.
Quick answers on the PPI washout, pH-impedance versus Bravo, whether it hurts, and when it needs repeating after surgery.
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What does a bundled HRM and reflux study show?
Two things at once — how the muscle of your oesophagus contracts and coordinates a swallow (manometry, graded on the Chicago Classification 4.0), and how much acid and non-acid material refluxes back up over 24 hours to several days (pH-impedance or Bravo, graded on the Lyon Consensus). Together they diagnose motility disorders, quantify reflux and rule out achalasia before anti-reflux surgery.
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Why do I need this before a fundoplication or LINX?
Anti-reflux surgery on the wrong physiology is the classic route to a bad outcome. HRM confirms your oesophagus can handle a wrap and rules out achalasia (which would contraindicate fundoplication and mandate a myotomy). Reflux monitoring confirms your symptoms are actually driven by pathological reflux, not functional heartburn. It is a standard-of-care workup, not optional.
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Do I really have to stop my PPI for a week?
For the reflux monitoring, yes — unless your consultant explicitly tells you otherwise. Studying acid exposure on a PPI answers a different question (whether the PPI is working) rather than the diagnostic question (whether pathological reflux exists). Speak to the referring consultant if the washout would be intolerable — there are structured alternatives.
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What is the difference between pH-impedance and Bravo?
pH-impedance is a thin catheter through the nose for 24 hours that measures acid and non-acid reflux. Bravo is a small wireless capsule clipped to the oesophageal wall at endoscopy that measures acid only, over 48 to 96 hours — no catheter, so it’s tolerated better, but it doesn’t detect non-acid reflux.
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Is manometry painful?
Uncomfortable rather than painful for most people. A little local anaesthetic is applied to the nose before a thin catheter is passed. You can breathe, swallow and speak throughout. The full study takes about 45 minutes.
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When would this be repeated after surgery?
Persistent dysphagia, recurrent reflux or new symptoms after fundoplication or LINX warrant repeat HRM and reflux monitoring. The workup after surgery is interpreted differently — a good post-surgical wrap deliberately alters the manometric profile.
Related tests
Looking for a different test?
-
Oesophageal manometry
Standalone HRM without reflux monitoring — motility question only.
Learn more -
Bravo pH study
Wireless 48–96 hour catheter-free pH monitoring.
Learn more -
Reflux monitoring
24-hour transnasal pH-impedance for acid and non-acid reflux.
Learn more -
All tests
Browse every test and procedure we arrange.
Learn more
In practice, in London
The London pathway for high resolution oesophageal manometry and reflux monitoring
With high resolution oesophageal manometry and reflux monitoring, the London question is usually about report turnaround and the radiologist reading it — not whether the scan is available. The wait for high resolution oesophageal manometry and reflux monitoring on the NHS depends heavily on where you live and how urgently the referral is graded. Central and West London private clinics can normally book within a week, with imaging or a procedure slot to follow shortly after. It’s worth being honest about the reason for going private: usually it’s time, not a fundamentally different test.
In practice, a private high resolution oesophageal manometry and reflux monitoring appointment in London means a named consultant, a proper hour in the room (or the equivalent on a video call), and a report you can actually read. Most of the imaging suites and endoscopy units we use sit within a mile of Harley Street or in Chelsea and Fulham, and turnaround on findings is measured in days, not weeks. For high resolution oesophageal manometry and reflux monitoring specifically, the difference between a routine report and a sub-speciality read is where private care earns its keep.
We’re careful about what a private pathway for high resolution oesophageal manometry and reflux monitoring can and can’t promise. It can compress a wait, put you in front of a subspecialist quickly, and get a proper report in your hands within a week. It can’t rewrite what the imaging or the bloods say. Setting that expectation up front tends to make the whole experience less stressful.
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