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Specialist upper GI diagnostics · UK

Oesophageal physiology, in a proper specialist lab.

High-resolution manometry, 24-hour pH-impedance, Bravo capsule and EndoFLIP - the specialist tests that separate reflux from achalasia, from spasm, from a hiatus hernia, and that decide whether medical therapy, endoscopy or surgery is the next step.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Indicative pricing

What private oesophageal physiology costs in the UK.

Indicative ranges across UK physiology labs.

In short

£1,300–£2,400, reported within two weeks.

Test Indicative range
High-resolution manometry (HRM) £600–£1,100
24-hour pH-impedance monitoring £700–£1,300
Bravo wireless pH capsule (48–96 h) £900–£1,600
EndoFLIP (add-on to OGD) £600–£1,000
Videofluoroscopy (VFSS) with SLT £450–£900
FEES with SLT £350–£700
Barium swallow / timed barium £300–£600
Full pre-anti-reflux surgery workup £1,500–£2,600

Prices vary by lab, by whether an OGD is bundled in (needed for Bravo and EndoFLIP), and by whether the report includes upper GI MDT discussion.

The problem

The right test, in the right order, in a proper lab.

Oesophageal physiology is done properly in only a handful of tertiary UK centres. Elsewhere it gets tacked onto a general endoscopy list, reported without Chicago v4.0, and the wrong test is done for the wrong question. We fix all three before you book.

  • Reflux that hasn’t settled?

    A 24-hour pH-impedance study on and off PPIs works out whether reflux is really the driver - before another prescription is changed.

  • Facing anti-reflux surgery?

    HRM excludes achalasia and pH-impedance confirms pathological reflux. Skipping this is why fundoplications fail.

  • Difficulty swallowing?

    HRM plus barium or EndoFLIP separates achalasia, EGJ outflow obstruction, spasm and stricture - each treated very differently.

When it helps

When oesophageal physiology changes management.

The situations we see most, plus the red flag that means a two-week wait OGD first rather than a physiology booking.

  • Reflux that hasn’t settled on PPIs

    Persistent heartburn, regurgitation or acid taste despite twice-daily PPI - pH-impedance confirms whether reflux is really the problem.

  • Dysphagia (difficulty swallowing)

    Food sticking, slow swallowing, or a sense of blockage - HRM plus barium or EndoFLIP work out whether it’s achalasia, a stricture or dysmotility.

  • Non-cardiac chest pain

    Cardiology has cleared the heart. HRM and pH-impedance look for oesophageal spasm, hypercontractile oesophagus or reflux-related pain.

  • Regurgitation of undigested food

    Classic for achalasia or a large hiatus hernia - HRM plus timed barium swallow is the diagnostic combination.

  • Chronic cough of unclear cause

    ENT and respiratory have looked. pH-impedance picks up non-acid reflux that PPIs and standard tests miss.

  • Pre-anti-reflux surgery workup

    Essential before Nissen, Toupet or LINX - HRM excludes achalasia, pH-impedance confirms pathological reflux. Skipping this is why some fundoplications fail.

  • Persistent post-surgery dysphagia

    Difficulty swallowing after fundoplication or LINX - HRM and EndoFLIP assess whether the wrap or ring is too tight.

  • Red flag: dysphagia + weight loss

    Progressive difficulty swallowing with weight loss needs a two-week wait OGD first - not a physiology lab booking.

The tests

The physiology toolkit, explained.

What each test actually measures - and which question it answers.

  • High-resolution manometry (HRM)

    A thin catheter with 36 pressure sensors measures oesophageal muscle contractions during ten swallows. Reported using Chicago Classification v4.0 - achalasia I/II/III, EGJ outflow obstruction, spasm, hypercontractile oesophagus, ineffective motility, or normal.

  • 24-hour pH-impedance monitoring

    A thin nasal catheter sits in the lower oesophagus for 24 hours. Measures acid (pH) and non-acid (impedance) reflux. A DeMeester score above 14.7 confirms pathological reflux.

  • Bravo wireless pH capsule (48–96 h)

    A pH capsule is clipped to the oesophageal wall during an OGD. No nasal catheter, so you eat and sleep normally for 48–96 hours. The capsule falls off within seven days and passes through the gut.

  • EndoFLIP

    A balloon-tipped probe measures lumen distensibility and cross-sectional area at the oesophagogastric junction during an OGD. Used for EGJ outflow obstruction, achalasia phenotyping, EoE assessment and intraoperatively during Heller myotomy or POEM.

  • Videofluoroscopic swallow study (VFSS)

    A modified barium swallow - dynamic X-ray imaging led by a Speech and Language Therapist. First-line for oropharyngeal dysphagia, aspiration risk, post-stroke or post-head-and-neck-surgery swallowing.

  • FEES

    Fibreoptic Endoscopic Evaluation of Swallowing - an SLT-led nasal endoscopy that watches you swallow food and fluids of different consistencies. Complementary to VFSS, and portable to the bedside.

  • Barium swallow

    A contrast fluoroscopy study of oesophageal anatomy. Picks up strictures, hiatus hernia, the classic “bird’s beak” of achalasia, epiphrenic diverticulum, or a mass.

  • Timed barium swallow

    A quantitative version used to grade achalasia and monitor response to Heller myotomy, POEM or pneumatic dilatation.

Safety and practicalities

What to expect on the day - honestly.

Oesophageal physiology is a safe outpatient investigation. The things worth planning are stopping PPIs on time, tolerating the catheter, and having someone to collect you if sedation is used.

  • Nasal catheter tests are uncomfortable, not painful

    HRM and pH-impedance need a thin catheter passed through one nostril. Local anaesthetic spray helps. Most patients tolerate it well; a few find the gag reflex difficult.

  • Transient sore throat and nose

    A mildly sore throat, hoarse voice or nose is normal for a day or two after catheter tests. A little bleeding at the nasal passage settles on its own.

  • Rare vasovagal syncope

    Very occasionally patients feel faint during catheter placement. The physiologist stops, lays you flat, and it settles within a few minutes.

  • Bravo capsule detachment

    The wireless capsule usually falls off within seven days and passes through the gut unnoticed. Early detachment shortens the recording; persistence beyond two weeks is rare and occasionally needs endoscopic removal.

  • EndoFLIP needs sedation

    EndoFLIP is done during an OGD, so the usual sedation risks apply - you need someone to collect you and cannot drive for 24 hours.

  • PPIs stop seven days before pH testing

    To measure baseline reflux, PPIs are stopped for seven days (H2 blockers for three days). Alginates and antacids are allowed as rescue.

  • You can eat normally on pH studies

    The whole point is to record real-life reflux. You are asked to eat your usual meals and note them in a diary.

  • A normal test is a useful result

    If HRM is normal and pH-impedance shows no pathological reflux, that changes management - anti-reflux surgery is off the table and other causes are looked for.

  • Red flags

    New progressive dysphagia, unintentional weight loss, vomiting blood or black stools need urgent OGD, not physiology testing first.

Reading your physiology report

Your report in four parts. Read the last one first.

Whichever combination of tests was done, the physiologist’s report keeps to the same shape.

A UK specialist gastroenterologist reviewing an oesophageal physiology report

A quiet reminder

Chicago v4.0 language is precise and can read technically - ask your care team to explain it if anything is unclear.

Ask your care team to explain anything that is unclear.

  1. 01 Header

    Which tests, on what medication

    Which studies were done, whether you were on or off PPIs, and the position of the catheter or capsule.

  2. 02 Technique

    HRM swallows and Chicago v4.0 metrics

    The ten test swallows, the integrated relaxation pressure (IRP) of the EGJ, distal contractile integral (DCI), and distal latency - the numbers that drive the classification.

  3. 03 Findings

    Motility diagnosis and DeMeester score

    The Chicago v4.0 diagnosis - normal, achalasia I/II/III, EGJ outflow obstruction, spasm, hypercontractile or ineffective motility - plus the DeMeester score from pH-impedance.

  4. 04 Impression

    What it means for treatment

    Read this first: whether medical therapy, endoscopic treatment (dilatation, POEM) or surgery (Heller, fundoplication, LINX) is the next step - and any test the MDT wants to add.

Recognised by major UK insurers

BupaAXA HealthVitalityAvivaWPACignaHealixBupaAXA HealthVitalityAvivaWPACignaHealixBupaAXA HealthVitalityAvivaWPACignaHealix

Cover for oesophageal physiology varies by insurer - usually funded when clinically indicated (refractory reflux, dysphagia, pre-anti-reflux surgery).

Frequently asked

Everything we get asked about oesophageal physiology.

Quick answers on what the tests involve, DeMeester scores, Chicago v4.0 and why the workup matters before anti-reflux surgery.

  • Why do I need oesophageal physiology tests before anti-reflux surgery?

    Because roughly one in twenty patients referred for anti-reflux surgery actually has achalasia or another motility disorder, and a Nissen fundoplication in those patients makes things worse. HRM excludes achalasia; pH-impedance confirms that reflux is really the driver of your symptoms. Skipping these tests is the commonest reason fundoplications fail.

  • Does high-resolution manometry hurt?

    It is uncomfortable rather than painful. A thin catheter is passed through one nostril to the lower oesophagus using local anaesthetic spray. Placement takes a minute or two, then you swallow ten small sips of water lying down. The whole test is 15–20 minutes.

  • What is the difference between 24-hour pH-impedance and the Bravo capsule?

    Both measure reflux. The 24-hour catheter is cheaper, faster to fit and reports both acid and non-acid (weakly acidic) reflux - the standard pre-surgery test. Bravo is a wireless capsule clipped during an OGD; it records for 48–96 hours with no nasal catheter, which lets you eat and sleep normally and picks up day-to-day variation.

  • What is EndoFLIP and when is it used?

    EndoFLIP is a balloon probe that measures how distensible the oesophagogastric junction is during an OGD. It is used for EGJ outflow obstruction, to phenotype achalasia, to assess eosinophilic oesophagitis, and intraoperatively during Heller myotomy or POEM to check the muscle release is adequate.

  • How much does private oesophageal physiology testing cost in the UK?

    Indicatively: HRM £600–£1,100, 24-hour pH-impedance £700–£1,300, Bravo £900–£1,600, EndoFLIP £600–£1,000 as an add-on to OGD. A full pre-anti-reflux surgery workup runs £1,500–£2,600 across two visits.

  • Do I need to stop my PPIs before the test?

    For pH studies, yes - PPIs are stopped seven days before, and H2 blockers three days before, so we can measure your true baseline reflux. Alginates and antacids are allowed as rescue. HRM alone does not require stopping acid suppression.

  • What is a DeMeester score?

    A composite score from 24-hour pH monitoring that combines the total time acid is in the oesophagus, upright and supine reflux time, number of episodes and length of the longest episode. A score above 14.7 confirms pathological acid reflux.

  • What is Chicago Classification v4.0?

    The international system used since 2020 to interpret HRM. It groups results into normal motility, EGJ outflow obstruction, achalasia types I, II and III, absent contractility, distal oesophageal spasm, hypercontractile (jackhammer) oesophagus and ineffective oesophageal motility - each of which points to a different treatment.

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