Esophageal Dysmotility

Aka: Esophageal Dysmotility, Esophageal Motility Disorder

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II. Physiology

  1. Swallowing (Deglutition) is started
  2. Upper esophageal sphincter relaxes, then 2 seconds later, lower esophageal sphincter relaxes
  3. Food bolus passes from oropharynx into upper Esophagus
  4. Esophageal peristalsis carries food bolus from throat to Stomach
    1. Contraction of one esophageal segment via excitatory Neurons
    2. Relaxation of next esophageal segment below the contracting segment via inhibitory Neurons

III. Types: Esophageal Dysmotility

  1. Decreased or inactive esophageal contractility (<5% of referred cases)
    1. Esophageal Achalasia
      1. Achalasia is the most important and potentially most severe of the Esophageal Dysmotility disorders
  2. Increased esophageal contractility (<5% of referred cases)
    1. Esophageal Spasm
    2. Hypercontractile Esophagus ("Jackhammer Esophagus")
  3. Functional Esophageal Disorders (<30% of referred cases)
    1. Analogous to Irritable Bowel Syndrome and Functional Dyspepsia
    2. As with Esophageal Spasm, may present with Chest Pain, heart burn or Dysphagia
    3. May also have increased hypercontractility on manometry
    4. Benign course that is self limited
    5. May respond to non-pharmacologic strategies employed in other functional disorders
  4. Gastroesophageal Reflux Disease (55% of referred cases)
  5. Eosinophilic Esophagitis (8% of referred cases)
  6. Opioid-Induced Esophageal Dysmotility
    1. May present in similar fashion to other Esophageal Dysmotility disorders

IV. Symptoms: Esophageal Dysphagia

  1. Sensation of food becoming stuck in the throat, neck or chest
    1. Perceived location of stuck food does not correlate with the actual location of obstruction
  2. Palliative Factors
    1. Patients may attempt to relieve obstruction with standing and walking
  3. Provocative Factors
    1. Emotional stress or anxiety
    2. Alcohol
    3. Rapid eating
  4. Associated Symptoms
    1. Regurgitation of food may occur several hours after a meal
    2. Solid AND liquid Dysphagia is more suggestive of dysmotility
    3. Chest Pain
      1. Chest Pain associated with meals may occur with Esophageal Dysmotility
      2. Chest Pain unrelated to meals is more likely to be a functional esophageal disorder or Esophageal Reflux

V. Differential Diagnosis

  1. See Dysphagia
  2. See Dysphagia from Esophageal Cause
  3. See Dysphagia from Oropharyngeal Cause

VI. Evaluation

  1. Step 1: Optimize Gastroesophageal Reflux Management
    1. Maximize acid suppression (e.g. Proton Pump Inhibitor)
    2. Optimize Non-Medication GERD Management
      1. Non-caffeinated fluid daily (e.g. 64 oz)
      2. Decrease Caffeine, Alcohol and provocative foods
      3. Tobacco Cessation and Alcohol cessation
      4. No food 2 hours before lying supine
      5. Elevate head of bed
  2. Step 2: Decrease or eliminate Opioids
    1. Opioid-Induced Esophageal Dysmotility is increasing in Incidence
  3. Step 3: Consider functional esophageal disorders (nearly as common as GERD)
    1. Strategies address modulating esophageal hypersenstivity and hypervigilence
    2. Stress reduction and relaxation
    3. Consider Cognitive Behavioral Therapy
    4. Tricyclic Antidepressants (e.g. Amitriptyline 25 mg or Imipramine 50 mg qhs)
  4. Step 4: Upper Endoscopy
    1. Indicated in all patients with Dysphagia (see red flags in GERD)
    2. Evaluate for malignancy and Barrett's Esophagus
    3. Identify structural lesions (e.g. Esophageal Stricture)
      1. Consider obtaining Upper GI Swallow (esophagram with barium)
    4. Identify inflammatory causes
      1. Eosinophilic Esophagitis
      2. Infections (e.g. candida Esophagitis)
    5. Achalasia findings
      1. Food retained in Esophagus
      2. Increased resistance across esophagogastric junction
  5. Step 5: Esophageal Manometry (high resolution)
    1. Indications
      1. Dysphagia (esp. liquid) and Chest Pain refractory to maximal medical therapy
      2. Achalasia suspected
      3. Endoscopy without other cause identified
    2. Technique
      1. Performed with Nasogastric Tube with closely positioned pressure sensors
      2. Esophageal pressures are measured as the patient swallows various foods and liquids
      3. Lower esophageal sphincter pressure is also measured before Swallowing and during relaxation

VII. Management

  1. Do no harm
    1. Functional disorders and Hypercontractile Esophagus improve or resolve spontaneously in a majority of patients
    2. GERD Management and functional techniques, with reassurance is effective in most cases
    3. Achalasia, however, is an important diagnosis with available definitive therapy
  2. General Measures
    1. See Step 1-3 in Evaluation as above
      1. Optimize GERD Management
      2. Discontinue Opioids
      3. Stress management, consider Antidepressants and consider Cognitive Behavioral Therapy
    2. Mindful eating
      1. Eat smaller, more frequent meals
      2. Eat slowly
      3. Choose softer foods
      4. Avoid foods and situations that trigger symptoms
  3. Hypermotility
    1. Precautions
      1. These medications decrease lower esophageal sphincter pressure and may worsen GERD
      2. Smooth Muscle relaxants are best limited to hypermotility confirmed by manometry
    2. Agents
      1. Calcium Channel Blockers
      2. Nitrates (Nitroglycerin)
      3. Phosphodiesterase-5 Inhibitors (release nitric oxide)
    3. Other agents which are safe and may be effective
      1. Peppermint Oil (2 mints sublingual before each meal)
  4. Achalasia
    1. Myotomy (definitive therapy)
      1. Laparoscopic Heller Myotomy
        1. Incises Muscles of the distal Esophagus, lower esophageal sphincter and gastric cardia
      2. Peroral Endoscopic Myotomy
        1. Newer, more technically challenging, but less invasive procedure than the laparoscopic Heller myotomy
        2. Incises the same Muscles as the Heller procedure
    2. Pneumatic dilation (by endoscopy)
      1. Disrupts lower esophageal sphincter
      2. Not as effective or longlasting as myotomy (dilation may need to be repeated)
    3. Onabotulinumtoxin A
      1. Endoscopic injection into lower esophageal sphincter
      2. Unknown efficacy, but may be used in patients at too high risk for surgery

VIII. References

  1. Wilkinson (2020) Am Fam Physician 102(5):291-6 [PubMed]

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Related Studies

Ontology: Esophageal motility disorders (C0014858)

Definition (MSH) Disorders affecting the motor function of the UPPER ESOPHAGEAL SPHINCTER; LOWER ESOPHAGEAL SPHINCTER; the ESOPHAGUS body, or a combination of these parts. The failure of the sphincters to maintain a tonic pressure may result in gastric reflux of food and acid into the esophagus (GASTROESOPHAGEAL REFLUX). Other disorders include hypermotility (spastic disorders) and markedly increased amplitude in contraction (nutcracker esophagus).
Concepts Disease or Syndrome (T047)
MSH D015154
ICD9 530.5
ICD10 K22.4
SnomedCT 196614005, 40846004, 61100004, 79962008, 266434009
English Disorder, Esophageal Motility, Disorders, Esophageal Motility, Dysmotilities, Esophageal, Dysmotility, Esophageal, Esophageal Dysmotilities, Esophageal Dysmotility, Esophageal Motility Disorder, Esophageal Motility Disorders, Motility Disorder, Esophageal, Motility Disorders, Esophageal, ESOPHAGEAL MOTILITY DIS, esophageal dyskinesia (diagnosis), esophageal dyskinesia, Dyskinesia esophageal, Dyskinesia oesophageal, Esophageal Motility Disorders [Disease/Finding], esophageal motility disorder, esophageal motility disorders, dyskinesia esophagus, dysmotility esophageal, esophageal dysmotility, motility disorders esophageal, dyskinesia of esophagus, Esophageal dyskinesia, Dyskinesia of esophagus (disorder), Esophageal motility disorder (disorder), Dyskinesia of esophagus, Dyskinesia of oesophagus, Esophageal dysmotility, Oesophageal dysmotility, Esophageal dysmotility (disorder), Esophageal motility disorder, Esophageal motor disorder, Oesophageal motor disorder, Oesophageal motility disorder, Esophageal motility disorders, dyskinesia; esophagus, esophagus; dyskinesia, Esophageal motor disorder, NOS, Oesophageal motor disorder, NOS, oesophageal dysmotility, Dysmotility;esophageal, Dysmotility;oesophageal
Italian Discinesia dell'esofago, Dismotilità esofagea, Disturbo della motilità esofagea, Disturbo della mobilità esofagea, Disturbi della motilità esofagea
Dutch dyskinesia van de slokdarm, dyskinesia van de oesophagus, dyskinesia oesofageaal, oesofageale motiliteitsstoornis, dyskinesie; oesofagus, oesofagus; dyskinesie, Dyskinesie van slokdarm, oesofageale dyskinesia, Dyskinesie van de slokdarm, Dyskinesie, oesofagus-, Motiliteitsstoornis van de slokdarm, Oesofagusdyskinesie, Slokdarmdyskinesie, Dyskinesieën, oesofagus-, Oesofagusdyskinesieën
French Dyskinésie de l'oesophage, Trouble de la motilité oesophagienne, Dyskinésie oesophagienne, Dyskinésies oesophagiennes, Dyskinésies de l'oesophage, Troubles de la motilité de l'oesophage, Troubles de la motilité oesophagienne
German Dyskinesie des Oesophagus, Motilitaetserkrankung des Oesophagus, Motilitaetsstoerung des Oesophagus, Dyskinesie oesophageal, Motilitätsstörung, Ösophagus-, Ösophageale Dysmotilität, Ösophagusmotilitätsstörungen, Speiseröhrendysmotilität
Portuguese Disquinésia esofágica, Disquinésia do esófago, Perturbação da motilidade esofágica, Discinesia esofágica, Discinesia Esofágica, Transtornos da Motilidade Esofágica
Spanish Discinesia de esófago, Trastorno de la motilidad esofágica, Discinesis esofágica, disquinesia esofágica, disquinesia de esófago, trastorno motor del esófago, trastorno motor del esófago (concepto no activo), trastorno de la motilidad esofágica, disquinesia de esófago (concepto no activo), dismotilidad esofágica (trastorno), dismotilidad esofágica, Discinesia esofágica, Dismotilidad Esofágica, Trastornos de la Motilidad Esofágica
Swedish Esofagusmotilitetsstörningar
Finnish Ruokatorven liikehäiriöt
Russian PISHCHEVODNOI PERISTAL'TIKI RASSTROISTVA, PISHCHEVODA PERISTAL'TIKI RASSTROISTVA, NUTCRACKER PISHCHEVOD, ПИЩЕВОДНОЙ МОТОРНОЙ ФУНКЦИИ РАССТРОЙСТВА, PISHCHEVODNOI MOTORNOI FUNKTSII RASSTROISTVA, NUTCRACKER ПИЩЕВОД, ПИЩЕВОДА ПЕРИСТАЛЬТИКИ РАССТРОЙСТВА, ПИЩЕВОДНОЙ ПЕРИСТАЛЬТИКИ РАССТРОЙСТВА
Japanese 食道異常運動, 食道運動障害, くるみ割り機状食道, ｼｮｸﾄﾞｳｳﾝﾄﾞｳｼｮｳｶﾞｲ, 食道ジスキネジア, ｼｮｸﾄﾞｳｼﾞｽｷﾈｼﾞｱ
Czech Dyskineze jícnu, Jícnová dyskineze, dysmotilita jícnu, ezofágus - poruchy motility, poruchy motility jícnu, Porucha motility jícnu, Jícnová porucha motility
Korean 식도의 수의운동장애
Croatian EZOGAGUSNI MOTILITET, POREMEĆAJI
Polish Zaburzenia ruchliwości przełyku, Zaburzenia motoryki przełyku, Zaburzenia czynności motorycznej przełyku, Zaburzenia czynności ruchowej przełyku
Hungarian Oesophagus dyskinesis, Nyelőcső dyskinesis, Oesophagus dyskinesise, Nyelőcső mozgászavara, Oesophagus motilitás zavara, Oesophagealis motilitási betegség
Norwegian Motilitetsforstyrrelser i øsofagus, Motilitetsforstyrrelser i spiserøret, Øsofagus, motilitetsforstyrrelser, Motilitetsforstyrrelser, øsofagus
Derived from the NIH UMLS (Unified Medical Language System)

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