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

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

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